§ Order for Second Reading read.4.44 pm
§ The Minister for Health (Mr. Kenneth Clarke)
I beg to move, That the Bill be now read a Second time.
The Bill spans the whole field of health, personal social services and social security concerns. Its 27 clauses and eight schedules range across a large number of topics, hence its rather extraordinary title.
The Bill represents the Government's continued commitment to measures which will promote and protect health and welfare and make the best use of available resources. Its principles attracted a broad measure of support from both sides in another place, where it has already been considered. In the light of the general welcome that the Bill received in another place, I find it extraordinary that there are rumours that the Opposition parties intend to divide against it this evening, but no doubt we shall hear more about that in due course.
There are four main broad objectives in the Bill. The first is to provide more care for the elderly, the mentally ill and the handicapped at the place where the patients and their families would prefer to be, that is, at home or in small units near to home. Too many patients still have to live in large, impersonal institutions, occupying hospital beds for long periods simply because the community services are not there to support them at or near home.
The second objective is to improve children's services, ensuring adequate safeguards for those who are most vulnerable or at risk. Thirdly, the Bill aims to get the maximum amount of patient care out of the growing resources made available to us by reducing bureaucracy and increasing efficiency and effectiveness. The fourth aim is to improve the quality of decision-making and the independence of decisions and appeals in the difficult area of national insurance and social security benefit claims.
Obviously, I do not intend today to describe in detail all the Bill's provisions. If I were to do so there would be little opportunity for hon. Members to take part in the ensuing debate. Instead, I have selected those provisions which I believe to be of most interest to the House and which typify the underlying principles of the Bill. I shall then mention briefly the Bill's remaining provisions. If hon. Members wish to probe further on particular issues, my hon. Friend the Under-Secretary of State will be happy to answer specific queries.
I begin with the first of the broad aims that I have described—the proposals for improving community care. Last July we announced the details of a very important initiative, which we call the "Care in the Community" programme. The most important change is that for the first time ever district health authorities will be able to offer to local authorities and voluntary organisations guaranteed annual payments without limit of time to provide for people moving out of hospitals into community care. We want to see resources moving with the patient so that the funds go with him to provide him with the right sort of care in or near his home.
§ Mr. Robert Kilroy-Silk (Ormskirk)
The hon. and learned Gentleman has said that he is concerned to improve community care. As the Bill says that it will not involve any increase in public expenditure, surely he 493 cannot realise that objective. All he is doing is transferring money from one quarter to another; he is robbing Peter to pay Paul. There will be no substantial increase in benefits to community care.
§ Mr. Clarke
I shall deal later with the substantial increases in public expenditure that flow from our whole policy in this area, as announced last July. The legislation is changing the rules, where necessary, to implement the policy. If the hon. Gentleman will contain himself, I shall explain later the relationship between the two. I am describing the most important single initiative in our "Care in the Community" policy—the provision under which we are giving to health authorities the facility to transfer resources with patients where the patients would be better treated at or near home.
Going back to the July announcement, secondly, we have improved the rules governing joint finance from the National Health Service so that it will be available for extended periods for projects for moving people out of hospital. Thirdly, we are promoting a programme of pilot projects and we shall be spending £15 million of joint finance moneys over the next five years for that purpose. Since we announced the initiative last July, we have added another £6 million to the pool of joint finance moneys as part of the £80 million of increased spending on the National Health Service that we announced in the autumn.
We have kept increasing the funds available for joint finance, and over £300 million has now been spent in that way since the Government have been in office. With the extra £6 million announced for next year, we have increased joint finance funds by 51 per cent., compared with the funds being expended when we took over from the Labour Government.
We have been consulting local authorities about the policy, and I am glad to say that we are about to issue guidance on those parts of it that require administrative action. However, further improvements to the rules on joint finance require legislation. They are contained in the Bill. We wish to extend the use of joint finance to education for disabled people and to housing, including sheltered housing for elderly and disabled people. Those services are an integral part of the pattern of service that is needed to support in the community the people about whom we are concerned.
The principal aim of part I of the Bill is therefore to enable health authorities to support housing and education expenditure by local authorities, other statutory bodies and voluntary organisations. The rest of part I consolidates existing provisions for joint finance and makes them more flexible.
§ Mr. Lewis Carter-Jones (Eccles)
Recently we debated the implementation of the Education Act 1981. We were told that no more resources were available. Is the Minister suggesting that what he is talking about may provide extra resources for the education of disabled children?
§ Mr. Clarke
It could have that effect. As the law stands, the joint finance moneys that I have described and that we keep increasing cannot lawfully be expended for educational or housing purposes. The hon. Gentleman will know as well as any of us that often we make provision for disabled children in the community—[Interruption.] 494 When the Opposition ask questions, they might as well listen. If the reply is more favourable than they expected, they do not seem to want to hear it. We are now facilitating some educational expenditure where that is part of the service that is required—for instance, for disabled children when we are moving them out of long-stay hospital wards, which often are not the best provision, to smaller community units and so on. We hope that voluntary bodies, health authorities and local authorities will come together to provide—
§ Mr. Clarke
I am sure that when the hon. Gentleman studies my reply, he will understand it. I thought that he was inviting me to repeat it again briefly. I am always happy to repeat the more attractive parts of our proposals.
§ Mr. Carter-Jones
Why does the Minister not talk to his hon. Friend the Under-Secretary of State for Education and Science, because two nights ago he said that there were no more resources?
§ Mr. Clarke
My hon. Friend speaks of his education budget. I am talking about the budget of my right hon. Friend the Secretary of State for Social Services and the use to which the ever-growing pool of joint finance money can be put by health authorities. The hon. Gentleman should support the Bill on this ground alone. The Bill alters the law to enable joint finance funds to be used for educational purposes.
For Wales only, part I of the Bill provides parallel powers for the Secretary of State to make payments for the development of community care. These will enable my right hon. Friend the Secretary of State for Wales to act directly to promote community care where this would be the most effective and efficient measure in a situation where he controls the expenditure of the range of bodies involved. This power is essential to him if he is to pursue his widely welcomed strategy of developing care for the mentally handicapped over the next 10 years.
Clause 2 makes similar provisions for Scotland to the first part of clause 1 for England and Wales in that it will enable my right hon. Friend the Secretary of State for Scotland to extend the scope of the existing support finance scheme to include payments in respect of education and housing as well as social work.
Before we leave this part of the Bill and care in the community, I draw hon. Members' attention to a provision later in the Bill that has some relevance here. I have referred several times to voluntary organisations. Of course, they make a vital contribution in providing care and support for thousands of people outside hospital. They are already involved to some extent in joint planning with the health and local authorities, but we intend to encourage further that involvement.
We have therefore included in schedule 4 an amendment to the law governing membership of joint consultative committees. Those committees are at present made up of representatives of health and local authorities. They advise the authorities on the planning and operation of services of common concern. The new provision will add members appointed by voluntary organisations. That will strengthen the present arrangements for involving voluntary organisations on the planning and operation of services of common concern. The new provision will add members appointed by voluntary organisations. That will 495 strengthen the present arrangements for involving voluntary organisations in the planning and provision of services, including those provided as part of our care in the community programme.
Part IV of the Bill contains provision for improvements in the registration arrangments in England and Wales for voluntary and privately run residential and nursing homes. Our intention is to contribute to our wider policies of better community care for dependent people. We are talking about the standards and the law that govern privately provided residential and nursing homes. The Opposition, in their attacks on private sector provision of care and health care, which they feel obliged to make regularly, often reveal how little they know about the reality of private provision. The bulk of private beds are not in private hospitals, but in small nursing homes. In total, they look after well over 20,000 elderly people and are run by a mixture of voluntary, charitable and commercial enterprises. They are an essential component in the country's provision for the elderly and disabled.
However, anxieties have been expressed over a number of years about the possible vulnerability of dependent people who need residential care, particularly the vulnerability of residents in establishments that fall outside the existing arrangements for registration and inspection by local authorities. Last year we had consultations on proposals to improve those arrangements when we produced the consultative document that we entitled "A Good Home". The consultation confirmed the need for some changes in the legislation governing the registration of the homes. In future, all persons, including corporate bodies, running a residential establishment with four or more persons in need of personal care because of old age, disablement or mental disorder, will be required to register the premises as a residential care home. That is not so at present. The change will ensure that boarding houses and similar concerns are registered if dependent people, who were, for example, patients in mental hospitals, are cared for. It is made clear in the Bill that it is not our intention that group homes for persons who are learning how to overcome a handicap or disability and make themselves less dependent should be required to register.
§ Mr. Laurie Pavitt (Brent, South)
I welcome the Minister's point about the 20,000 people who are looked after in private nursing homes, which is useful to the community. However, will the Minister compare that figure with the 470,000 beds in the geriatric service in the NHS and the large number of places in warden-assisted homes run by local authorities?
§ Mr. Clarke
The number of beds provided by the NHS vastly exceeds those provided by the private sector. The contribution that is made by the private sector, particularly in residential and nursing homes for those who do not require full hospital residence but wish to live in such an establishment, is substantial. The hon. Gentleman's intervention illustrates what is too often wrong with our health debates. The moment I make a favourable reference to residential homes run by voluntary or charitable bodies up and down the country he leaps up to defend the NHS. The two are not incompatible. We are talking about private provision, which is essential, and which adds to and supplements the NHS.
§ Mr. Clement Freud (Isle of Ely)
Does the Minister accept that while my right hon. and hon. Friends and I welcome the Bill and will not vote against it—
§ Mr. Clarke
The present proposals are for local authority registration and inspection, which happens now. No one has complained about the quality of the registration and inspection. We are merely extending the scope of the present arrangements. I shall explain the other ways in which we are strengthening them. We shall consider in Committee the problem of what happens if undesirable characters are moving about. One suggestion is that there should be a national register. However, such proposals are often difficult to administer in practice. We shall consider the point and no doubt return to it in Committee.
Residential care homes will no longer be excluded from registering as nursing homes. The possibility of this dual registration will permit greater flexibility of care within a single establishment.
We propose to make substantial changes to the system. Regulations will specify the minimum frequency of inspection of residential care homes. It is intended that they should occur at least once a year. The maximum fine for operating an unregistered home will be increased from £500 to £1,000. In place of appeals to the courts, there will be a unified system of appeals to tribunals similar to those previously constituted under the Child Care Act 1980. To cover the cost to local authorities arising from their registration and inspection responsibilities, the registration fee will be increased from the present £1 and there will be an annual fee.
In addition to those legislative provisions, we believe that a non-statutory code of good practice could promote greater consistency of standards in many homes. Therefore, we have accepted an offer from the Centre for Policy on Aging to form a working party of people experienced in the care of the elderly and other dependent people to draw up such a code. The working party is now sitting. The National Association of Health Authorities has already set up a working party to draw up similar guidelines for nursing homes. Those changes will bring authorities into closer relationship with the private and voluntary sector and should, in many cases, result in an improved standard of care. This should in turn encourage authorities to make better use of the resources available to them in the private and voluntary sectors.
Social security adjudication is an abrupt change of subject, but the proposals represent an important reform that will be welcome to many hon. Members.
§ Mr. Kilroy-Silk
Does the hon. and learned Gentleman intend to talk about the Bill's proposals for dealing with children in care?
§ Mr. Clarke
I shall deal with that point briefly, but my hon. Friend the Under-Secretary of State proposes to deal with that at more length when he replies to the debate because he is particularly concerned with that aspect. [Interruption.] Hon. Members can hardly complain. I should have thought that it was better for a Minister to deal with the subject having heard hon. Members' views first. I propose to deal now with social security adjudication.
§ Mr. Andrew F. Bennett (Stockport, North)
If the Minister can confirm that he will retain the House of Lords' proposals on mandatory training, we can save much time. However, if he insists on taking them out, many hon. Members will want to take time to argue the case.
§ Mr. Clarke
The Government are still considering their reaction to the House of Lords' proposals. We are consulting our colleagues in the Department of Education and Science. The hon. Gentleman will have to contain himself until we reach that stage of the Bill in Committee.
Benefit claims, appeals and adjudication greatly concern hon. Members in many constituency cases which come to them. There has been much criticism of the existing adjudication system over the years. Clause 18 and schedule 7 deal with that subject. The provisions are intended to improve the quality of adjudication and decisions and to demonstrate more clearly the independence of the arrangements for deciding benefit claims from the Department. We hope that the Bill will also speed up the process—another welcome improvement.
We are making four main changes. First, we are merging national insurance local tribunals and supplementary benefit appeal tribunals into a new single network of social security appeal tribunals. The new legal structure of the supplementary benefit scheme that was introduced in 1980 has made that possible. The Bill will require all chairmen of the new tribunals to be legally qualified. I assure the House that the intention is not to make the hearings more legalistic or formal in any way. However, lawyers will be better able to cope with the detailed supplementary benefit regulations. Hon. Members will know that "detailed" is something of an understatement. In conducting the hearings they will also be able to ensure a better overall standard of hearing for claimants.
The change will not be made immediately. There will be a transitional period during which existing lay chairmen may be appointed as chairmen of the new tribunals. Members of the new tribunals will be drawn from panels of people with local knowledge and experience. Trade unions will continue to be invited to nominate members. Another important change will be to invite nominees from other groups which represent claimants, such as those representing elderly and disabled people and single parents.
§ Mr. Dafydd Wigley (Caernarvon)
Does the Minister accept that many chairmen with practical experience, who may not be legally qualified, could well take the advice of legally qualified men and could carry out the responsibilities of chairmen better even than those legally qualified but without such experience?
§ Mr. Clarke
As I have said, for those who have been chairmen the transitional arrangements will allow them to continue and to be appointed as chairmen of the new tribunals. There will only be legally qualified chairmen for future appointments. The other appointments will be laymen from trade unions and other organisations representing single parents and so on. Judgment, knowledge of the world and common sense will be a collective matter for the tribunals. The reason for having a lawyer as chairman is because of his familiarity with conducting hearings and his ability to cope with the maze of regulations which form the background to the claims 498 and to make a decision which is subject to proper judicial consideration thereafter in those few cases where things go wrong as a matter of law.
§ Mr. Carter-Jones
Why cannot men and women with knowledge of the world chair the committees and be legally advised? Why must we have a lawyer as chairman?
§ Mr. Clarke
We shall have a tribunal comprising a cross-section of experience. We shall have only a legally qualified chairman. There is no question of lawyers alone deciding what often can be very difficult matters of judgment.
In addition to setting up the new social security appeal tribunals, we shall appoint a president, regional chairmen and some other full-time chairmen to exercise oversight of the new tribunals. These appointments will help both to improve the quality of tribunal adjudication and to strengthen their independence of the Department of Health and Social Security. This part of the new tribunal system can best be explained to the House as being modelled closely on the arrangements for industrial tribunals, the procedures of which most hon. Members will agree have given rise to little or no complaint over the years since they were established. The move in that direction is a welcome improvement on the much criticised present arrangements.
In the first place, claims will be decided by independent officers simply called adjudicating officers. They will replace the existing adjudicating authorities—insurance officers, benefit officers and supplementary benefit officers. In addition, a new statutory post of chief adjudication officer is being created to provide guidance to adjudication officers and to keep the adjudication system under review. We intend that those changes will emphasise the unity and independence of the people who make the first decisions in every case.
The fourth change is to the arrangements for medical adjudication under the industrial injuries scheme. We are removing the present restriction on a claimant's right of appeal to a medical appeals tribunal contained in the proviso to section 108(2) of the Social Security Act 1975. At the moment that prevents a claimant appealing against a provisional assessment of the extent of disablement within the first two years following the reference of his claim to a medical panel. With the removal of the restrictions, the claimant's rights will be virtually unfettered.
We are also providing for disablement questions to be determined in the first instance by one doctor in most cases. A recent survey carried out by the Department showed that most disablement benefit claims involve relatively straightforward medical issues and do not justify the involvement of two doctors as is normally the case in medical examinations at present. Therefore, in future it is intended to use one doctor only, more extensively in the adjudication of more straightforward cases. However, I emphasise that two doctors will continue to be used in those cases where a second medical opinion is desirable. In due course, regulations will set out the circumstances in which two doctors will adjudicate.
§ Mr. Brynmor John (Pontypridd)
Who will decide whether two opinions are desirable—the doctor or the appellant?
§ Mr. Clarke
The regulations, which will be drawn up in due course, will describe the circumstances in which 499 two doctors will adjudicate. One makes a comparison with the kind of consultations and treatments that take place outside. It is plainly not the case that each and every claim for industrial injury benefit calls for a second opinion. We shall draw up regulations which attempt to define carefully and fairly those cases requiring two doctors.
§ Mr. Andrew F. Bennett
Is it not a serious contempt of the House to say that in due course regulations will be drawn up? Any Government bringing forward a Bill should have the regulations in outline, at least, so that it can be seen how they fit into the Bill. Surely the Minister can tell us what is in the regulations.
§ Mr. Clarke
It is not an abuse of the House. When one seeks a regulation-making power, hon. Members in Committee legitimately ask either for the draft regulations, if they are ready, or for some explanation of what they will contain. We shall give that in Committee. All that I am describing for the purpose of this debate is that, because one will have to define with care the circumstances in which a second doctor is required, we shall take a regulation-making power to determine those circumstances.
§ Mr. John
It is not just the regulations. The hon. and learned Gentleman does not have a clue about the principle. What will the principle be? Will a second doctor undertake the examination jointly—not a second opinion—at the instance of the appellant, or merely at that of the other doctor or the tribunal?
§ Mr. Clarke
I shall say what we intend broadly; we shall go into the matter in greater depth in Committee. The regulations will include and stipulate all cases involving diagnosis or recrudescence of prescribed diseases or where the claimant has applied for review on the grounds of fresh evidence or unforeseen aggravation. In Committee we shall consider the precise range of the regulations and what else might be included. Taken together, subject to the detailed points which must be considered, I suggest that the provisions that we propose for social security adjudication will considerably simplify and streamline medical and other adjudication processes. They will strengthen the position of claimants and lead to a substantial saving in administrative costs.
Children's services have been referred to by the hon. Member for Ormskirk (Mr. Kilroy-Silk) and others. As I said, those important parts of the Bill that deal with children's services will be dealt with in detail by my hon. Friend the Under-Secretary for Health and Social Security when he winds up the debate. The Bill makes a number of changes in children's legislation, which will provide increased protection for vulnerable groups of children. For example, paragraph 8 of schedule 1 gives greater protection to children whose parents have a record of child abuse, so that the child can be placed under a supervision order. The Bill provides that in cases where the parent refuses to allow the supervisor to visit the child, or to have the child medically examined, a warrant can be sought from the magistrates court. The warrant will enable a constable to search for and, in some cases, to remove the child to a place of safety.
Other changes introduced by the schedule will enable local authority services to be extended to wider numbers of children in care. We have also taken the opportunity to make technical corrections to earlier legislation to clarify its intention.
500 My hon. Friend the Under-Secretary will also give our present views on the difficult subject of parental rights and access to children in care, which we have been considering with considerable care.
§ Mr. Kilroy-Silk
I apologise for intervening a second time, but this is important. The Minister will recall that in another place the Under-Secretary made a commitment to engage in consultations on changes in social work practice and procedure for children taken into care. To what extent have those consultations taken place, with whom and with what result?
§ Mr. Clarke
Consultations are taking place with local authorities about guidance, but we are also considering the legal position. It is a matter that will have to be gone into if the Bill goes through. I suggest that in the interests of time my hon. Friend the Under-Secretary should be allowed to deal with that matter as he intends.
Part VII deals with local authority charges, in particular charging policy for local authority services. The provisions are based on the recommendations of a working group of central and local government representatives, which reported in 1980. This is the Government's first opportunity to seek the necessary legislative powers. From looking at this part of the Bill, hon. Members will see that it is a detailed subject and we shall have to leave a great deal to be dealt with in Committee.
In general terms, the provisions have two main objectives. First, they seek to introduce consistency between the various powers under which local authorities may charge for the services they provide and the basis upon which charges are made by different authorities. Secondly, they are intended to secure a fair deal for those who have to pay the charges and, specifically, to ensure that no one who needs a service is charged more than he can afford.
Clause 11 deals with charges for day and domiciliary services such as home help, meals on wheels and aids and adaptations. For Scotland only, it embraces all the services provided under the Social Work (Scotland) Act 1968, including charges for residential services and contributions towards the maintenance of children in care. If they make charges for these services, local authorities are required to set them at a reasonable level. Following discussions in another place, we are considering with local authority associations what should be taken into account in determining what is reasonable, the need to issue guidance to local authorities on this issue and the possibility and practicability of exempting from charges those on low incomes and with small capital resources. I hope that the discussions will be completed in time to report the outcome in Committee.
Family practitioner services and family practitioner committees are affected by part V. The Government are committed fully to the development of primary health care, which for most people is their main and, in many cases, their only contact with the NHS. We have shown our commitment in a variety of ways to the importance of improving primary care in inner cities. We have announced recently that we have earmarked £3 million to be spent on improvements in inner city primary care during the next financial year.
In our view, the proposals in part V will better equip family practitioner committees to make a full and valuable contribution to the provision of primary health care. The 501 Bill requires the Secretaries of State to establish, for England and Wales, family practitioner committees to replace those established by district health authorities. The purpose is to simplify the present complex administrative arrangements whereby the committees are accountable direct to the Secretaries of State for arrangements for the provision of family practitioner services but must look to the DHAs for their staff, accommodation and equipment.
The administrative dependence of FPCs on DHAs has caused problems of delegation and accountability and has led to the creation of an unnecessarily complex bureaucracy. Therefore, in future, if the House approves the Bill, the Secretaries of State will establish the committees and appoint their chairmen, vice-chairmen and other members. We intend to consult fully on nominations and preserve the traditional balance between contractors and non-contractors within the committees.
§ Mr. Mike Thomas (Newcastle upon Tyne, East)
When it is generally accepted that the principal problem for family practitioner committees is not the bureaucracy of which the Minister speaks—although we are in favour of getting rid of unnecessary bureaucracy—but their relationships with other parts of the health and social service departments and other bodies, how will moving them further from the ambit of the DHAs, rather than further in, help to integrate primary care?
§ Mr. Clarke
I agree that the hon. Gentleman has identified the main problem. That is why I am trying to point out that the Bill is concerned only with administrative arrangements and management responsibilities. It is important, of course, that we ensure that, whatever arrangement we have for the administration and employment of staff, we encourage close collaboration between the new FPCs and DHAs in the planning of provision of primary health care. We shall do that by ensuring cross-membership with DHAs. There will be members in common on both the FPCs and the DHAs. The DHAs will continue to be responsible for producing comprehensive local health plans.
We do not intend to extend the functions of family practitioner committees beyond those which they are at present required to undertake. At least one member of the FPC will be a nurse with community experience. We propose that there should be both formal and informal local arrangements to ensure satisfactory communications between FPCs and DHAs.
For the first time, family practitioner committees will also be represented on the existing joint consultative committees which involve local authorities in the planning of health and personal social services. Given that we shall be directly responsible for the FPCs in all the policies that we shall follow, we intend to try to bring about the closest possible collaboration between health authorities, FPCs and local authorities to produce the right service.
§ Mr. Mike Thomas
I agree with those worthy objectives, but can the Minister explain why the arrangements that he is now proposing will be more beneficial in integrating primary care into our health system than the arrangement that was recommended by the Royal Commission of the FPCs becoming primary care committees of the district health authorities? That is the logical thing to do. Is this not just a pay-off to a vested interest?
§ Mr. Clarke
If the hon. Gentleman manages to catch your eye, Mr. Deputy Speaker, no doubt he will describe the vested interests which he believes we are paying-off. This legislation is designed simply to sort out an administrative tangle. At the moment the responsibility is direct to the Secretary of State. That is necessary because the Secretary of State is answerable for the overall standards of family practitioner services. However, those services look to the district health authorities for their staff. I shall return to this point, because I believe that it lies behind the fact that some hon. Members intend to vote against the Bill tonight. They are becoming excited about a change that concerns only management—who employs whom. The big issue is the policy. It is absurd for people to be excited about matters that concern bureaucrats more than patients. I believe that we are aiming in the right direction.
§ Mr. David Ennals (Norwich, North)
Surely this measure will add to, rather than decrease, the bureaucracy, which was the recommendation of the Royal Commission. Cannot the Minister see that point, and also that it will be much more difficult for joint planning if one has such a separately constituted body? Will there not be more centralisation and more decisions taken by the Secretary of State? Surely we wish to get away from that in the Health Service. It is staggering that the Minister should put forward such a proposal.
§ Mr. Clarke
At the moment there is a clear line of responsibility for these arrangements up to the Secretary of State. We are ensuring that management responsibilities and accountability lie in the same direction. All the other provisions that I have described—the cross-membership with district health authorities, the membership of the FPCs and the fact that we shall put the FPCs on the joint consultative committees—should mean that their policy objectives are brought closer together.
We also intend that the provisions governing public admission to meetings will be extended to FPCs and that their relationship with community health councils should be similar to that with the district health authority.
The only way in which we may be centralising to a modest extent is that the administrative expenditure of family practitioner committees will continue to be cash limited and subject to the same checks that apply at present to health authorities. They will appoint their own staff and be responsible for their administrative arrangements and management costs. Under the new arrangements FPCs will be both accountable to Ministers and called to account for their administrative expenditure.
§ Mr. David Crouch (Canterbury)
I hope that my hon. and learned Friend will not press the point about separation of the FPCs too strongly on the House and in Committee. He talks disparagingly about bureaucrats, but I have worked for 12 years in the administration of the Health Service and I am worried about whether this legislation will mean better or worse management. I hope that my hon. and learned Friend will listen to the debate. If I catch your eye, Mr. Deputy Speaker, I shall try to explain my point of view as one who has worked closely with the Health Service for a long time.
§ Mr. Clarke
Most people who have been connected with health authorities have decided that such matters should be the responsibility of health authorities. Most 503 people who have served on family practitioner committees have told us that their duties should not be given to the local authorities, but should be separate. I respect my hon. Friend's long experience on a regional health authority, but the question of who appoints whom is not the biggest issue facing those services. All that we shall ensure—
§ Mr. Clarke
We shall change it because, as I explained a moment ago, the arrangements left to us by the right hon. Gentleman are a dog's breakfast. No one suggests that we should carry on as we are at present. We have chosen to go this way because it gives a clear line of accountability to the Secretary of State and it enables us to cash limit the administrative expenditure and to make the committees accountable for efficiency. [Interruption.] Obviously Opposition Members, as they have shown throughout the afternoon, are worried about anything that reduces the costs of the Health Service. I do not know which union is briefing them on this matter, but no doubt a union is upset that the people concerned might be in the wrong branch if they are transferred.
There is a division of opinion in the Health Service, but we are trying to get clear lines of responsibility for administrative expenditure. At present the Secretary of State is responsible for the services provided. Every other policy and initiative that we are taking will encourage closer collaboration between local government, health authorities and FPCs. The management changes are unimportant compared with that.
§ Mr. Mike Thomas
The hon. and learned Gentleman has condemned himself with his own mouth. If he wishes to cash limit those operations, which I do not dispute, why does he not include them in the district health authorities, which are cash limited?
§ Mr. Clarke
If we cash limit the administrative expenditure of FPCs, one can hold them clearly accountable for the part of the expenditure that they incur. If we muddle them all up with the district health authorities, that will become more difficult. The judgment is finely balanced. I assume that the hon. Gentleman does not object to our cash limiting the administrative expenditure of the FPCs. We are describing a clear way of making them accountable.
I shall not describe the other provisions in the Bill in detail. I hope that I have mentioned the major areas. However, several other proposals will improve legislative arrangements generally, although they do not introduce major changes. Part II introduces more flexibility to the planning of children's services. Part III provides for a reduction in membership of the Central Council for Education and Training in Social Work and permits more flexible working arrangements for the council. Part VI enables doctors who have been suspended from the medical register on the ground of ill health to be paid during suspension. Part VIII removes an isolated statutory requirement to set the fees for notification of infectious diseases by statutory instrument and abolishes several bodies which, in our opinion, have outlived their usefulness.
§ Rev. Martin Smyth (Belfast, South)
The Minister went over part III very quickly. I appreciate that the details of education can be considered later. Part III refers to 504 persons resident in Great Britain, but it is the only part of the Bill that also deals with Northern Ireland. Should it not talk about persons resident in the United Kingdom?
§ Mr. Clarke
If that part of the Bill applies to Northern Ireland, we may need a drafting amendment. However, we shall let the hon. Gentleman know our opinion on that before we go to Committee and we can discuss it and correct it, if necessary, in Committee.
The Bill received a broad welcome in the other place and it contains many enlightened social reforms and changes in the administration of the social security system. I hope that we shall not hear from the hon. Member for Crewe (Mrs. Dunwoody) or from anyone else that the Bill is controversial. I was told at one stage that the Opposition would vote against the Bill on Second Reading as a matter of principle. The Liberal party has already pledged its support and the Social Democrats appear to be quite happy. The hon. Lady's reaction to most of our policy proposals is so predictable that I fear that, if she is not careful, she will bounce up to vote against this measure before she has thoroughly reflected upon the worthwhile changes that we have made. I wait to hear what lies behind any anger that Opposition Members may feel, and I hope that it is not simply their objection to the new arrangements for the family practitioner committees. That is an argument about management and how best to reduce bureaucracy and is not the main point of the Bill.
A vote against the Bill would put in jeopardy the "Care in the Community" proposals, the improved protection of vulnerable children, better standards for nursing homes, better decisions on appeals in benefit matters—[Interruption.]—The hon. Member for Crewe does some extraordinary things and I should not be surprised if she invites her hon. Friends to vote against all those matters simply because once we get on to a part of the Bill that deals with simplifying administration and sorting out a managerial tangle the Opposition will have listened to other people. One can always rely on the Opposition parties to oppose anything—
§ Mr. Clarke
The Labour party has its priorities, as we have ours. The Bill makes it clear that our priorities are the better care of patients and the improvement of the system, and it will be widely welcomed for that fact.
§ Mrs. Gwyneth Dunwoody (Crewe)
It is a good thing that we are debating this Bill on a day when it has become clear that the Conservative party has an interesting view of the welfare state.
We were told by the Prime Minister earlier that she believed in the setting up of the family policy group because that would enable everyone to have greater choice. It seems that there is a new virility test in the Conservative Government for their brothers—certainly not for their sisters because they do not seem to have any sisters in the Government. The brothers have to give evidence that they are a bigger vandal than anyone else by bashing the welfare state. Apparently, Ministers have been asked to put up ideas about policies for which they have no departmental responsibility. That is one way to get carefully researched and thought-out policies.
What is intended after the next general election, if the electorate are conned into allowing the return of the 505 Conservative Government, is the reduction of the welfare state to the point where it is simply a minimum safety net for welfare needs. The Prime Minister has made it clear that the family policy group has been set up not just to advise. She has apparently asked for specific decisions, and the decisions that she is looking for are only too clear.
The right hon. Lady regards any kind of welfare provision as being the responsibility of the family. She defines the family in an extremely narrow way. For her, the woman of the household is the one who should be encouraged to stay at home and the one who should have responsibility for the disabled and the elderly. The Prime Minister also apparently suggests that in future the woman of the household should have responsibility for the unemployed 16-year-olds because she intends to remove any benefit from those who make the grave mistake of not finding a job or of getting themselves on to one of her unworkable work schemes.
It is not only those sectors of the community that will be affected. The single parent families will be affected. The family policy group demands whether the present policies strike the right balance between adequate child support to prevent child poverty and encouraging responsible, self-reliant behaviour by adults. What utter hypocrisy. We heard today from the Minister how many children are living in families where the income is below that which should be acceptable in any civilised country. We know that there are increasing numbers of single parents in the community. Yet the Government are seriously considering whether they can change the support given to those in need.
We desperately need a change in primary care. If the Minister had presented a Bill that was not just a ragbag of odds and ends of improvements and tiny adjustments here and there, but a positive way of moving money into the community and of shifting resources from the NHS to where they are most needed, he would have had the warmest welcome ever. It is not acceptable simply to say that community care is wanted if one is not prepared to talk about the finance for providing precisely the services that make the difference in the community.
The Bill could have provided us with a heaven-sent opportunity for a new beginning, but instead of seizing the chance to relaunch the National Health Service and the social services the Government have run away from major problems. Care in the community should represent a commitment to improving the quality of life for those who are most deprived. One cannot dump the old or the mentally handicapped or mentally ill back on to already over-burdened local authority services and say that one is caring for them where they are happiest.
One improves community services by making sure that not only the local authorities but the social services departments and all the relevant NHS services have sufficient money to back up staffs that provide that high level of care that should be endemic in any such idea.
I welcome in the Bill acceptance of the fact that joint financing is the way that both the NHS and the social services can begin to promote that level of care in the community. Unfortunately, the Minister, who has been congratulating himself on the widening of the terms of joint financing, has omitted to say that the amounts of money involved are very small.
506 Unfortunately too, in the overall financing of the NHS, the amounts allowed for joint financing are minimal. We should also take account of one very worrying factor. It is nonsensical to suggest that joint financing will be able to replace existing funding in social service budgets. Without confidence in real growth, local authorities will not take on new commitments or new schemes. They have made it clear that they are exceedingly reluctant even to consider extending the amount of joint financing.
In 1981, 22.2 per cent. of the area health authorities reported that they would not take on any new joint financing, and, although the Minister has told us that £96 million is to be allocated for this purpose in 1983–84, it will now have to stretch very much further than before. Local authorities have been subjected over the past three years to direct attacks on their social service budgets. The effect of that has been to cut back on the amount of sheltered housing, on the provision of personal social services and on the community services that would make the difference that the Bill envisages.
We realise, then, that the extension of the categories, about which we have heard so much today, is an empty gesture. There is no point in providing improved rules or access if there is no money on the table to provide the services when it comes to the point of committing the budget. The Government, almost inevitably, give the impression that they desire to unload responsibility for certain categories of the ill and underprivileged on the community, but not to pay for the services.
Pilot projects of £15 million over five years sound very impressive until account is taken of the existing cuts in local authority finance that have already restricted the provision of their services. The Select Committee on Social Services has already said that, although many local authorities have gone out of their way to protect their social service budgets, they are now having to accept that even those vital services are suffering from the effect of Conservative policies.
§ Mr. Tim Sainsbury (Hove)
If the local authorities are as short of cash as the hon. Lady is suggesting, how are they able to waste many millions of pounds on campaigning for such things as the Campaign for Nuclear Disarmament, and on such wasteful and irrelevant things as declaring an area to be a nuclear-free zone? Would it not be much better if that money were spent on the joint financing scheme?
§ Mrs. Dunwoody
The hon. Gentleman is involved in a firm from which somebody has been appointed to look at the management of the NHS and should be extremely careful before intervening, not least because one suspects that the reason the managing director of one of the grocery firms has been appointed to carry out this survey is that there are already many low-paid people in the distributive trades, and presumably he has a great deal of experience in making sure that not too many staff are taken on on proper rates.
§ Mr. Sainsbury
That is a gratuitous attack on an able manager, instead of an answer to the question, and it is characteristic of the hon. Lady. I take it that she wants the NHS to continue to be as badly managed as possible so that the worst possible service is given to the patients.
§ Mrs. Dunwoody
I want the National Health Service to be managed by people who understand that patient care is not the same as dealing with tins of baked beans. Some Conservative Members seem unable to understand that.
Most aspects of the Bill are concerned in some way with primary care. The Minister has dealt with a number of them. Like him, I apologise if I seem to leap from one subject to another. One of the problems is that the proposed legislation is so unstructured. I shall take the various matters in the order in which I believe that they should be considered.
With regard to the family practitioner committees, the Minister said that he hoped for far closer integration of planning and services in the National Health Service in the future. Anyone who knows anything about community care knows that only with close integration of the primary care services, the NHS and the local authorities can the health of our people be improved. Unfortunately, far from being more closely integrated into the work of the NHS and the local authorities, the FPCs are actually being moved in the opposite direction. Serious planning cannot proceed when one arm of the primary care services is in some ways divorced from the district health authority.
Our objection to the Bill's proposals is that there is already a difficulty in relation to the independent status of the general practitioner. To exacerbate that by creating an independent structure for the family practitioner services is not, therefore, a very constructive decision.
There is also considerable criticism of the Minister's decisions about the appointment of FPCs. In the past, there was some local input through the local authority representatives. Now, however, the Secretary of State apparently intends to remove that local involvement. He intends, for example, to appoint the chairmen and vice-chairmen himself. In the past few years, we have had a great deal of experience of what happens when the Secretary of State appoints representatives. The chairmen appointed in the reorganisation of the district health authorities seem far more noted for their commitment to the interests of the Conservative party than for their knowledge of the Health Service. If the Secretary of State intends to follow that example in this case, one must be very worried about the chairmanship of family practitioner committees.
The Secretary of State has also made it clear that he intends to act as a kind of filter for local nominations. Instead of those nominations being accepted, he apparently now intends to decide which of the people nominated are acceptable to him. We already know of the instance in which the Under-Secretary of State for Health and Social Security, the hon. Member for Hampstead (Mr. Finsberg), wrote to various family practitioner committees asking for information about the political affiliations of some of their members. It was explained in the House that this was not because he really wanted to know their political affiliations but because he wanted to know how to address a letter. Some people—I am one of them—find that rather difficult to swallow. If there is to be direct political control over the membership of health authorities, the Minister should say so openly rather than making out that he is simply proposing a small change in the administration for management reasons. The proposal is that the Secretary of State will not only appoint the chairmen and vice-chairmen but will filter the other nominations from local organisations.
§ Mr. Kenneth Clarke
The hon. Lady has now passed her first and only example of our alleged political bias in making appointments. She does not do the reputation of the service or anyone else any good by scraping the barrel in an attempt to make out that all the appointments are party political. The biggest change made since I have been in office was the appointment and reappointment of the 14 chairmen of regional health authorities. The hon. Lady has several times alleged that they were all political appointments. Of the 14 appointed, three have been—one certainly still is—active members of the Labour party engaged in politics. The idea that we showed party political bias in those appointments is plainly nonsense. What we did and shall continue to do is to choose the right people for the job.
§ Mrs. Dunwoody
I can only say that it is extremely interesting that the Minister knows the political affiliations of the chairmen appointed. That gives strong support to my point. He has still not made it clear that the local authorities or the locally nominated members will effectively be chosen by the people concerned and riot by the Secretary of State.
The Minister made a great deal of the question of cash limiting family practitioner committees. It is helpful at this point to consider the whole subject of the financing of those committees. In 1950, the general medical services co-ordinated by the FPCs took up 30 per cent. of the NHS budget. By 1982–83, the proportion had fallen to 22.8 per cent. Over the past five years, spending on FPCs has increased by 127.2 per cent. and on the NHS in general by 113.6 per cent. Those are gross figures, however, and include the extra revenue from charges. These rose from £98 million to £303 million in the same period. Under this Government, the gross increase in FPC spending has been 93.1 per cent. compared with 88.2 per cent. for the NHS generally, but charges have increased from £105 million to £303 million or 188.6 per cent.
Therefore, talking about cash limiting the FPCs gives a very different picture from the amount that ought to be considered. The Select Committee on Social Services reported that FPC growth after pay and price increases was 4.6 per cent. If one subtracts from that the amount needed for demographic change and the high-tech factor it becomes a 0.9 per cent. cut. If the Secretary of State intends to control the FPCs, he will have to explain on what basis that calculations is made.
There is a good case for examining the entire role of the general practitioner in relation to the NHS. Ministers have the Acheson report and they must now take urgent action rather than simply saying that they intend to do something in the long run to improve primary care services. In considering the provision for general practitioners, they should examine the way in which the GP's role is integrated into the planning of the National Health Service.
The entire Bill directly affects primary health care in a number of ways. The Government are very free with their advice to patients and families to consider how many more of the elderly should seek accommodation in the private sector. In that context, I welcome the proposal for registration of old people's homes in an attempt to create a proper code of practice. When we reach that point in Committee, however, I shall be asking the Minister why 509 many provisions that I regard as elementary and important are not written into the Bill but left, presumably, to a voluntary code of practice.
Why, for example are no standards for homes in the private sector, in terms of staffing or general qualifications, written into the Bill? Why is there no written commitment to fire standards and safety standards?
I find very worrying the suggestion that the problem of increasing geriatric illness in our society can be contained by hiding people away in ghettos that consist of old boarding houses with minimal conditions. This development should be closely monitored. Why is it suggested that there should be only one annual visit to inspect such premises? There should be a minimum of one visit every six months. One visit should be made without warning. I hope that the Government will state clearly their intention to extend the inspectorate. I should like to see a national register of all the homes, of the qualifications of the owners and the managers and of people who, for one reason or another, have been removed from the list because of unsuitable behaviour. That information should be readily available not only to local authorities but to the families of patients. I should like to see a new clause accepted by the Government to extend those powers.
I wish to deal now with the worrying question of the divesting of assets of elderly people going into homes. There is no point in hon. Members discussing the use of geriatric units as a means of rehabilitating the old or improving the access to physiotherapy and psychogeriatric care if we introduce restrictions on the taking over of assets that would affect directly the chances of old people being able to go back into society and back into their own homes. I should have expected the Government to accept that the disregard in this instance should be the same as that for supplementary benefit. It should be £2,500 and not £1,200. Nowadays, such a sum could easily be available to an elderly person. It could make all the difference if they hoped to go back to their own home.
The elderly at home are extremely important. Cuts in social services budgets affect them immediately. I was told only this week of the case of an elderly patient who, as a result of cuts in the social services budget of a local authority, is now being put to bed by nurses at six o'clock in the evening. The woman occupies sheltered housing where the warden goes off duty at night. Because she is left for a considerable number of hours, she frequently gets up in the middle of the night. If she falls over, the emergency services have to be called to put her back to bed. If one calculates the cost of using the police and ambulance services as a means of replacing social services provision in terms of community nurses, one comes far closer to an accurate assessment of the cost of present Conservative policies upon people in their own homes.
In talking of the elderly, one also has to take account of other services such as home helps, meals and day care. Spending on day care has increased from £30.6 million in 1979–80 to only £31.8 million in 1980–81, expressed in 1980 prices. On home helps, spending fell from £196.8 million to £193.3 million. On meals, spending fell from £28.8 million to £26 million. Even these figures are overoptimistic. Once the increasing number of elderly is accounted for, the service levels per thousand aged over 65 fell by 8 per cent. for home helps, by 5.3 per cent. for meals, and by 2.6 per cent. for day care. There is a 510 consistent drop in the provision of support services for the elderly who are most in need. Nothing in the Bill even accepts the extent of the problem, let alone seeks to do anything to provide new funds.
I shall deal now with the Central Council for Education and Training in Social Work. It is difficult to understand why the changes made by the Bill are not more widely based. I was convinced that the Department would have consulted the social workers on the whole issue of training. It is known that the CCETSW is giving urgent attention to the training of social workers for approval under the provisions of the Mental Health (Amendment) Act 1982 which the Minister himself piloted through the House. It is therefore important that the standards of training in social work must be highly professional and acceptable to a wide number of people in the health professions. The Minister appears to be suggesting that there will be a drop in numbers in the council and that he will not be required to balance the interests of the bodies that are represented on it.
Why is the Minister not prepared to accept that he will not be able to produce high standards of training unless the council's work is carried out with the advice and help of everyone concerned? Why is the whole question of a mandatory grant not written into the Bill? The Minister has stated today that he is having talks with the Department of Education and Science. It seems that, if the level of professional social work is to be improved, money will have to be made available for training.
As many hon. Members wish to take part in the debate, I shall conclude by referring to the major issue of child care. I have been very disturbed by the attitude of the Government towards the maintenance of a national council to consider the effect of legislation on children. One of the most depressing and frightening features of the rising level of unemployment that the Government have engineered is that those who suffer most when there is great social stress are the children in the family. There is a rising tide of child abuse. The social services are being called upon to provide support in many more cases where there is not open abuse. It is therefore essential that all legislation should be examined for its effect on children. The Government did away with the council that would have reflected precisely that commitment. Although it was a statutory obligation, they have done little to remedy the fault. There should be an advisory council on child care. It should have a statutory responsibility to examine the effect of the work of this House on every family.
This is an unsatisfactory Bill, not least because it does not contain any of the changes that would have made a difference in primary care. The Government are free with their congratulations to themselves about their commitment to the National Health Service. In fact, they have no interest in, and no desire to improve, either primary health care services or the National Health Service as a whole. The Prime Minister has made clear that she believes that choice is a matter of depriving most of the underprivileged of the services that they require even to lead a civilised life. She has made it clear that it is her intention to move rapidly towards a system where the NHS is only a minimum safety net providing minimal facilities for those most in need.
The Opposition will divide the House because we regard the FPC decisions as unacceptable. We are concerned with the section on child care. The Labour party believes that the Bill is indicative of the view of the 511 Government. It might have had a direct effect in improving patient care but in the event it does nothing to provide improved services.
§ 6 pm
§ Mr. David Crouch (Canterbury)
I shall not be as intemperate as the hon. Member for Crewe (Mrs. Dunwoody) in her closing remarks. That is not how I feel about the Bill. Some parts of the Bill disliked by the hon. Lady are disliked by me, especially clause 8, which relates to the rearrangement of the family practitioner committees.
The hon. Lady introduced a strong political criticism. I am not making a political criticism of the Bill. I have seen the National Health Service at work for more than 12 years, and not only as a politician. As a member of a regional authority, I have served under five different Secretaries of State.
There have been Health Service debates on reorganisation over many years, and the House knows that I have frequently expressed concern at the separation of the provision of health care by the FPCs from the general central management—the NHS. How have they got away with it? They have done so under successive Ministers in successive Governments. They have flown in the face of strong recommendations made by the Royal Commission. The House is further separating the unique and distinct body of men and women who constitute the general practitioner service under the umbrella of the family practitioner committees.
I see clause 8 as the FPCs final break with the centre of management in the Health Service. From now on they will be dealing direct with the Secretary of State and the Department. I do not wish to say anything divisive or contentious this evening, but I wonder whether this is really right.
Schedule 4 provides that there will be essential links between the family practitioner committees and the district health authorities. When the second reorganisation of the National Health Service set up the district health authorities, it was said that they were the key to the management and delivery of health care. I am glad that there will be a link with this key to good management. It is not for managers alone to consider whether this or that system is good. Management must produce the right service for the patients—those who need the service. That is an important element of management.
The FPCs are to have the essential links that are spelt out clearly in the Bill. There is a need for co-operation. That is what these links are about. The schedule implies that there is a need for co-operation between the FPCs and the DHAs, especially as they are to be separated. It refers to securing and advancingthe health and welfare of the people.We all agree with that. There is nothing managerial about that. That is the aim of all of us in spending thousands of millions of pounds on the Health Service. We want to be sure that we are delivering that service and advancingthe health and welfare of the people.I am not convinced that the separation of the FPCs will produce better co-operation and advance the health and welfare of the people. There was considerable debate in the other place on this point. I have read the lengthy debates. The other place brings to these matters much expertise and knowledge of health provisions. I do not 512 think there are many there like myself—there are one or two—who can be categorised as managers, but there are many distinguished physicians and surgeons who can speak with great authority from many years' experience of the problems that they have seen.
I do not think any of the noble Lords spoke in a party political sense. The essence of Lord Rea's speech—I am not allowed to quote exactly what he said—was that even today, under the existing arrangements, it is not easy to communicate with the FPCs. Everyone who works at the sharp end knows that that is so.
As a layman in the Health Service, I recognise that it is difficult to deal with the FPCs. Why are doctors difficult, touchy and edgy? Why do they want to draw back so often? Doctors take the Hippocratic oath. They sometimes regard the things they do as secret—nobody must interfere with them or give them directions because there is a great secret involved. Perhaps it is only psychological, in the background and in the subconscious. I admire enormously the men and women in medicine at all tiers. However, I suspect that they sometimes find themselves wanting to withdraw into their shells because there is a secret involved.
It is essential that there should be co-operation between the GPs and the FPCs in the planning and delivery of primary health care. This is the most important element among those other specialties. If we can ensure better health at the beginning of one's life on this earth, we may be able to stop those other specialties from being required later in life.
Family practitioner committees are being given a clear signal that they are to be regarded as something special, distinct and different. They will deal directly with the Secretary of State. They are to be removed from the responsibility of improving services in the localities that they serve. I do not think it is intended, but they will be separated from the district health authorities.
I have taken part in two major reorganisations of the National Health Service. They were quite traumatic as we worked them through our system. We keep looking to see whether we should still further perfect them. General practitioners have never been fully integrated into the Health Service or in its planning for health care. They have always somehow eluded us. Neither the National Health Service nor patients have benefited as a result.
The National Health Service has always been criticised. Indeed, I have been a leading critic. I do not hesitate to say that. When one works in the Health Service, one tends not to visit general practitioners to see them at work but to visit hospitals to see what they are doing. This is the big element. I have often criticised the use of hospitals which were built more than 100 years ago and which are struggling to give a good and adequate service.
I have not often been able to get near GPs to criticise them. Why should I? We cannot enter GPs' consulting rooms, have a look round and say, "We are members of the regional health authority. We have come to have a look at you." Even the members of the community health councils cannot do that. I do not think that it would be healthy for the Health Service to have people looking over the shoulders of GPs all the time. However, when GPs form group health centres and group surgeries, they are proud to show them to us. These centres and surgeries are institutions, like small hospitals, and the GPs are proud to show us that they have a variety of services at their beck and call. We visit them because they are small institutions. 513 There are often pleasant reception-waiting rooms, and sometimes there is even a pharmacist at the end of the corridor. The doctors are proud to show the miniature hospital service that they can provide through their group surgery or group health centre.
Such a service costs a great deal of money and must be contrasted with the service that one of my constituents found recently when she attended the doctor in her village. The doctor, who was not a young man, had no partner. She told me that his office looked like—I hope that those in another profession will forgive me—a provincial solicitor's office. Apparently all the records were piled high on the doctor's desk and on other tables.
§ Mr. Crouch
The doctor was smoking a cigarette, and his first remark to the patient was "Would you like a fag?"
§ Mr. Crouch
This may seem an exaggerated description, but it is true as recounted to me. However, my constituent told me that he was a good doctor. His records could be found after a little searching among the documents on his desk. That is an example of the old type of management in the Health Service that is not easily spotted.
We criticise the Health Service but it is making advances. The service is improving. There are new specialties and new advances in medicine all the time and they are being made available to the patient. Above all, the NHS is for ever becoming more integrated with our general social needs. It marches alongside the social service departments. There may be criticism about how effectively the integration is taking place, but successive Governments have sought to bring the two services together to produce a general social as well as a health provision. The Bill goes a long way towards helping to bring about this unity.
The FPCs have chosen to work on their own; they are distinct and separate. I believe that they are out of step and out of time. I have described the atmosphere in an old surgery, but I have heard the FPCs described as quill-pen organisations. The GPs continue to work in the important area of primary health care. That is where the patient starts. Information about the patient begins to be obtained in the GP's surgery. That information is of interest not only to the GP and his patient. One of the advances of the NHS has been in information technology and computerisation. There is a need for computerisation to be population-based as well as patient-based. We need information for health observation generally. We need to develop at-risk registers. We need to improve screening techniques and immunisation records to expose dangerous gaps that are developing and signal essential needs so that we may try to eradicate them.
I am concerned that the separated FPCs may slow the process of population health statistics and studies which I believe to be important. Perhaps I am wrong in thinking that the FPCs will co-operate less in the arrangements that the Bill will introduce. I may be thinking too much along the lines of a manager and bureaucrat, which, of course, I am not.
514 My concern is for the patient. I have been trying to perfect and streamline management in the NHS for years to help the patient. I work closely with other members of health authorities, including GPs, consultants, nurses, administrators and others. The GPs have always been on the sidelines watching the game, unlike the consultants, who, from the very day that the NHS was set up, have been in the centre of things—in the middle of the scrum.
I am prepared to accept my hon. and learned Friend's assurances that he can achieve a better line of communication and better co-operation with the FPCs as the Government propose to set them up than if they remain in the present somewhat confused situation, in which they are neither one thing nor the other. I have always said that I would prefer to bring the FPCs into the DHAs and to involve doctors in all aspects of health provision, care and management. However, I shall be generous towards the Government. I have enormous regard for my hon. and learned Friend. In the short time that he has been the Minister for Health he has achieved a firm grasp of these complex issues. He has an understanding of the patient as well as of management. However, I am concerned that there might be separation in Health Service management instead of the complete involvement that could have been achieved by a different allocation of resources. This could have been achieved within the DHAs.
The provision of primary health care through the GP is something more than visiting or receiving a visit from him, the family doctor. The doctor has—or should have—a team behind him and a great variety of services at his command. He has much to offer his patients in the provision of primary care—for example, health visitors, midwives, district nurses and chiropodists. Can my hon. and learned Friend assure me that the FPCs and the GPs will work in full co-operation with the DHAs in the employment of their medical staff and nurses? There is some concern in the Health Service that they may go on their own and not integrate with the DHAs.
My hon. and learned Friend has implied that I have been thinking as a bureaucrat. I have merely sought to comment on the observations that I have made on the spot. I feel that there could be disadvantages in what the Government propose, but I hope that I am wrong. I hope that my concern that there might be disadvantages will be taken on board by hon. Members on both sides of the House. We must ensure an effective integration of the FPCs and GPs if we are to make real progress in the delivery of primary health care.
§ Mr. David Ennals (Norwich, North)
I hope that no one will accuse me of political prejudice in having confirmed the appointment of the hon. Member for Canterbury (Mr. Crouch) as a member of a regional health authority. I did so because I thought that he would be an extremely good member of it. His speech today has shown his deep understanding of the National Health Service. One of the troubles about so many of his colleagues is that they do not understand it. They are not present today, and that suggests that they do not want to understand it.
I welcome several parts of this polyglot Bill. It contains good things and bad things. I welcome the extension of joint financing, which was introduced when I was the Secretary of State for Social Services. It was clear that the next step had to be housing and education. The system was 515 established and the decision to extend has now been taken. I warmly welcome the registration and inspection of residential care homes.
My third welcome is for the provision of mandatory grants for training social workers. I hope that the Minister will say whether that will include approved social workers under the Mental Health (Amendment) Act 1982. There is much anxiety about where the resources for training approved social workers under the new Act will come from. It was a little strange for the Minister to present a Bill, parts of which he was not sure whether he supports. As the Bill was presented in the other place by Baroness Faithfull and supported by others there, I should have thought that he would know whether he approves of it. I hope that the Minister will answer that point when he replies.
There are also parts of the Bill which I deplore. I do not need to go into the points which the hon. Member for Canterbury made about what I call the hiving off into limbo of the family practitioner committees. That is contrary to the recommendations of the Royal Commission. I shall take the issue no further than that. I hope that the Minister will read carefully what his hon. Friend said. It sets out clearly the great mistake that the Government have made in that part of the Bill.
I also oppose those parts of the Bill that relate to charging for social services. The Bill was being discussed a few years ago, before the present Secretary of State took over from his predecessor. There was then a different team of Ministers. It was a miscellaneous provisions Bill, which we knew would appear. Many of us hoped and expected that if it did not take the action that we wanted it to take, the matter would be dealt with through the private Member's Bill of my hon. Friend the Member for Brent, South (Mr. Pavitt).
There could have been a restriction on advertising. We could have done something to tackle the massive problem of the 50,000 people who die prematurely each year as a result of smoking—induced diseases. The Minister knows that that represents a massive cost—about £150 million a year—to the National Health Service. If he wants to save money, why does he not provide for that problem? I know that it is difficult to do so in a Bill that has a title as long as this one, but why did the Minister not introduce generic substitution? That is another way of saving a massive amount of money. Someone has suggested £30 million. I think that it is more likely to be £100 million or £170 million. That is a large sum of money, which the Health Service needs desperately. I hope that the Minister will say that he will be prepared in Committee to examine this problem and measures to combat smoking, so that we can save a substantial sum of money that could be used in other parts of the Health Service that desperately need it.
§ Mr. Pavitt
Perhaps I might give my right hon. Friend another figure. The Pharmaceutical Association has said that there would be a saving of £29 million on 11 drugs alone.
§ Mr. Ennals
I am grateful to my hon. Friend. That is just a small number of drugs. In general, the figure is much higher.
§ Mr. Ennals
No, I should like to get on. Many hon. Members deeply resent the fact that, as a Privy Councillor, I have been called at all. [HON. MEMBERS: "No."] Hon. Members obviously like me more than I thought.
There is no attempt in the Bill to relieve the acute financial pressure on the NHS. Whatever twist the Secretary of State makes on the NHS's public expenditure circumstances, he knows that the service is not growing. Indeed, in many areas, there has been a decline in its services. This is the first time that that has ever been the case.
I shall quote from the Nursing Standard, which is the paper of the Royal College of Nursing. I thought it best to choose a body for which I know the Secretary of State has a great respect. It said thata substantial part of the extra £100 million has to be found from savings health authorities themselves will be forced to make through 'efficiency saving'—the now well-known euphemism for cuts.Indeed, the minister said that £40 million will come this way.And much of the £60 million that is left will be automatically absorbed by simply keeping pace with the growing demands on health services.The growing demand comes especially from elderly people. If one subtracts the £40 million that health authorities must save from the non-existent 1.2 per cent. which the Secretary has claimed is additional money, the true growth rate comes to 0.7 per cent. As the Minister knows, 0.7 per cent. is precisely the figure that we must provide every year to meet the growing needs of elderly people. Right across the nation there is a nil growth rate, and in many parts there are cutbacks.
The article in the Nursing Standard, quoting the Secretary of State, continues:In 1984–85 and 1985–86 health authorities are again expected to release further resources towards development of services of half per cent. in each year through continuing improvements in efficiency.The picture that we have now is that which the Secretary of State promises we shall see for the next few years if he continues as Secretary of State. I hope that he will not have the opportunity to be responsible for the Health Service.
The Bill makes it clear that there will be no allocation of funds to the things that the Opposition welcome. Paragraph 13 of the explanatory and financial memorandum says:There will be no additional public expenditure.Paragraph 14 talks ofsmall savings in administration costs.Paragraph 15 says that the flat-rate charge "may reduce receipts", and paragraph 16 talks of anet saving of approximately £2 million.Paragraph 18 says:The financial consequences of the remaining provisions of the Bill will be negligible.There are many things to be done but no money with which to do them. The Royal College of Nursing is not alone in holding those views. We must ensure that the money is made available.
We must also examine the Bill in the light of other things that are happening. The Think Tank's proposals to carve up the welfare state and to demolish the Health Service as we know it will now be temporarily shelved. If the Conservative party is re-elected, the proposals will come out, be dusted down and be ready. As was revealed in The Guardian today, a series of Ministers, chaired by the Prime Minister, are making plans that will crucify the welfare state that was designed by Lord Beveridge 40 years ago and implemented by successive Governments. 517 When we examine the Government's commitment, which the Prime Minister made clear yesterday, to their advertising campaign on behalf of recession-hit private bodies such as BUPA by inviting civil servants to pay their way into private insurance schemes, we can see the Conservative party's commitment, or lack of it, to the NHS.
Although there are many issues on which we shall agree in Committee, the next election will be fought not simply on issues such as the restoration of our shattered economy and the arms race, but on the future of the welfare state, to which the Opposition are deeply committed. I am all for self-reliance—the Government repeat that again in the Bill—for those who can be self-reliant, but it leaves in the cold, quite literally, the elderly, the mentally handicapped, the disabled and families who survive only on unemployment and supplementary benefit.
I want to make two or three brief comments, and the rest I shall leave for Committee. I said that I welcomed proposals to extend joint financing. I agree with the reaction of the Association of Directors of Social Services, which said:While we welcome the increased flexibility in these arrangements, our overall reaction to the Government decisions 'Care-in-the-Community' has been one of deep disappointment. Our evidence maintained that these measures would be seriously undermined if they were not backed up a substantial increase in funding".Even with joint financing, unless much more money is pumped in, what is done for housing and education will come out of what is being done for the social services. I believe that there should be guarantees. Many patients remain in hospital who could be better cared for and at no cost to the community if resources were made available to local authority social services departments. We have to look at the funding of both the NHS and social service departments.
Part IV deals with residential and nursing homes. With the growth in the number of elderly people, and the fact that local authority services have not kept pace with their needs, there has been a substantial increase in residential homes for the elderly and handicapped. Some of these private homes are good and I pay tribute to them. I have visited many of them in my constituency and elsewhere. I have no objection whatsoever to the involvement of the private sector, in co-operation with the local authority, in helping to meet the needs of these people.
Some homes are, however, very bad, and many homes that have high standards welcome the fact that there is to be registration, because they believe that all care homes should have the same high standards. Unfortunately, some homes are in the business of making money. That should not be their purpose. Age Concern said:At its best the private sector home is very good but at its worst it represents a scandalous exploitation of elderly people, who may be dumped by uncaring relatives with no questions asked for as long as the money lasts".Of course all these homes should be licensed—whether by local authorities or by a national registration agency, I am open to persuasion. I entirely agree with my hon. Friend the Member for Crewe (Mrs. Dunwoody) that inspections must be frequent and effective—at least twice a year. Moreover, I believe that they should be without warning. These homes should not have the opportunity to scrub everything, get people happy and give them good 518 meals for two or three days before, so that all the recollections are of good things. A proper inspection, in my view, is one that is carried out without warning. That is extremely important. Certainly there should be a list of homes that have been refused registration, or homes that have had their registration cancelled, so that they do not turn up, as has happened, in other parts of the country.
My final point concerns charges for local authority services in part VII. I am fundamentally opposed to the concept of charges for home helps. In Norfolk, even people on supplementary benefit are now charged for their home helps. It has meant that many people either do without them altogether or reduce the time for which they receive help. There is no doubt that charges deter. The home help service, which in the late 1970s was steadily expanding, is now contracting. This is appalling, at a time when we know that demand is growing and will continue to grow. Home help service is crucial to the health and the well-being of an increasing number of elderly people. It should be provided on the basis of necessity, and without charge to the client.
There are many other points that I could put and which I hope will be put in Committee. There are a number of items in the Bill that we welcome, but there are a number that we deeply deplore.
§ Mr. Kenneth Carlisle (Lincoln)
Despite what the right hon. Member for Norwich, North (Mr. Ennals) said about the voluntary sector and the role played by home helps, for example, I am sorry that he will not support the Bill, because it deserves to be welcomed. Its simple aim is to help the elderly and handicapped. I welcome it particularly, because it helps the voluntary sector which needs help. That sector provides excellent services for the community, and the community and the Government should help it. Let us take a simple view of the Bill and recognise that it does its best to support those people who wish to serve the community.
I shall concentrate on part I, which follows the consultative document "Care in the Community", published in 1981. Part I seeks to put some of the document's facts and recommendations into effect. I support part I and the voluntary sector for three reasons. First, it is quite wrong to believe that central Government can cope with all the health and care needs in any community. I have been in Parliament now for just over three and half years, and one of the main lessons that I have learnt is the incapacity of central Government to care for a community. However much money is poured in, great gaps are left in the care provided by central Government. That care can be provided only by people who know the community and the individuals, and have a passion to help. They fill in the gaps out of a sense of compassion and humanity.
Second, the voluntary sector uses many of the good features of any community. It gives people who want to help the community an opportunity to serve their fellow men, and it helps those who receive help from individuals. An example of that in Lincoln has been the establishment recently of a volunteer bureau. I visited the bureau last week, and it does a good job. People who want to help voluntary organisations, and who are perhaps out of work, go to the bureau and are directed to whatever voluntary activity suits them. This is an excellent service, and it shows the need in any community for voluntary effort.
519 The third reason why I support the Bill is that it makes sense to look after people within a community. That is what the people who need help want. They do not want to go into an institution or hospital. They would much rather stay in the community of which they are part, and where they are within reach of their friends and of the activities that interest them. Moreover, in times of economic difficulties, it is often much cheaper to look after people in the community. Once a person is in an institution, costs mount. That seems to be an irreversible law. If one wants economy of achievement and value for money, the aim must be to look after people in the community.
§ Mr. Mike Thomas
The hon. Gentleman must be aware that, except in the most unusual circumstances, if one provides proper support services in a community, it is usually more expensive for people who have anything seriously wrong with them to stay in the community than to go into institutional care. It is in the quality of life that the benefit lies, not in cost savings.
§ Mr. Carlisle
I would not agree with the hon. Member on all counts. There is no doubt that in Lincoln studies show that to look after old people in the community costs very much less than looking after them in a home. It may be right in some circumstances, but it is certainly not right in the majority of cases.
I should like to mention two examples in Lincoln where voluntary effort can be of tremendous help to the community. First, we have a very active and vigorous Lincoln Association for the Care of the Elderly. I have visited their two day centres and they are building up their facilities to include rooms where people may live as well as visiting on a day basis. I am tremendously impressed by the voluntary effort that goes into them. Several hundred people help with care in the centres in a variety of ways. One of the chief benefits is to organise a system where volunteers look after elderly people in a district to see that they are all right. They visit them once a day or every other day according to need. That is all organised on a local basis. The help and boost to morale that they give to local people is most impressive.
The other organisation in Lincoln which should be mentioned is Mencap, which looks after mentally handicapped people. It was set up entirely by voluntary effort and not only provides a day centre for these people but keeps them within the community and provides a helpful back-up service to parents who love their mentally handicapped children but find it a great burden to look after them throughout the day. They are enabled to go on holiday or have a day off. I am most impressed by the time that these dedicated people give voluntarily to that organisation.
There are many such institutions. I have already mentioned the elderly. We have two other small homes set up by people who like the elderly and wish to look after those who have left their families or who no longer have families to look after them. Thus they are kept in the community rather than going into local homes.
§ Mr. Carlisle
She has another seat, thank goodness.
Those homes could not do that without help from the local authority. This Bill will provide more help.
520 It is interesting to note that the aspect of joint financing has been warmly welcomed by Age Concern. I am sure that many Labour Members will also welcome it.
It is right to encourage voluntary effort, as this Bill sets out to do. It is both foolish and arrogant for any group of people to believe that Government can provide everything. They cannot. As I have pointed out, there are gaps in the provision of care and it is up to voluntary groups to fill those gaps. In the last year of the Labour Government only £33 million was provided for joint financing. That figure has risen, last year and in this year, to over £800 million. This shows that the Government have been prepared to put money into the voluntary sector.
I know that the efforts of the Government to support the voluntary sector have encouraged those who give their time and effort to it. Because of the trouble the Bill takes to look after people in need, I hope that Opposition Members will consider supporting such a worthwhile measure.
§ Mr. Clement Freud (Isle of Ely)
I follow the hon. Member for—I forget the name of the constituency and in any event it would be wrong to mention it yet again—who has given the House a completely new concept of the words "community care". This is such a ragbag of a Bill that it is very difficult to make a Second Reading speech. However, I welcome the Bill in general, and, seeing each other as we shall do in Committee, we shall know, as soon as the sittings motion is moved, how the wind will blow. I hope very much that it will blow favourably.
The most important aim of the Bill is to support community care by bringing people out of hospital and into the community. Helped by new provisions for joint financing, it extends joint arrangements to include housing and education in addition to local authority and voluntary social services. However, no extra money is available and, as the right hon. Member for Norwich, North (Mr. Ennals) said, community care is not a cheap option. In order for it to work effectively and to prevent people being left to suffer in their homes, more money should be made available. The point made by the right hon. Gentleman is that joint funding is not the creation of wealth; it is the confusion of finance.
In part VII, clause 11 sets out what will be subsection (5) of section 29 of the National Assistance Act 1948:Where a person avails himself of any service provided under this section, the local authority providing the service may recover from him such charges (if any) for it as they consider reasonable.We shall without much doubt amend that in Committee. It is generally accepted that when charges are made take-up falls dramatically. Like all Members on the Opposition Benches, I am fundamentally opposed to the concept of making a charge for what should be a statutory duty.
A study of the home help service in Warwickshire in 1977 found that clients paying full charges averaged 1.5 hours fewer per week than the average client and that part-payers received 0.7 fewer hours; that is, half. A study in Huntingdonshire in 1970 found that most home help organisers considered charges to be a deterrent. It is easy for the Government to publish figures and to ignore the fact that we now have more old people in need of more home helps. They publish not per capita but only global figures, and that is cooking the books in the way in which at 195 Melrose Avenue they apparently cooked people in 521 depth. Age Concern believes that the home help service is so crucial to the well-being and independence of elderly people that it should be provided on the basis of necessity and without charge to the client. I have always had a great admiration for Age Concern and agree with it fully on this.
At present local authorities can assume parental rights over children in an authority's care without telling parents, and they can do this on the advice of a social worker. This derives from the Poor Law Act 1889, passed in response to evidence that parents were placing children in the workhouse and allowing them to remain there when they were 10 years old and able to work. The Conservative party has often been accused of trying to send children up chimneys. If this is its concept of the meaning of "market forces", it must be reconsidered.
It is wrong that a child placed voluntarily into care can have parental rights transferred to the local authority without the knowledge of the parents and, in practice, on the advice of only one social worker who must, in theory, satisfy himself and the social services committee that one of several grounds is proved. It is only after the local authority has assumed parental rights that parents have to be told. They can then appeal to a juvenile court. An amendment must be introduced to give the power to assume parental rights of children voluntarily in care to juvenile courts in the first instance and to allow parents to be heard and represented.
On the registration of licensed residential and nursing homes, the Bill at present obliges local authorities to keep a register of residential and nursing homes. I mention local authorities because this is critical. I asked the Minister whether he agreed that this should be national, and he said "No". It is a worrying concept that if one has licensed premises, such as a public house, one has to go before the magistrates and information in respect of the licensee's suitability may come from all over the country. Anyone may object, and the police give evidence. The same applies to a casino. It ill becomes this or any Government to be seen to care more deeply for the drunks and the gamblers than for the old, the frail, the halt, the lame and those who most need help. The vast majority of homes are well run by caring people, but we all know that there are abuses. It seems to me wrong that it should be local authorities, counties, and not a national licensing system that is the deciding factor.
The British Association of Social Workers goes further than I do. It believes that local authorities should have the ability to establish from the police whether or not a person has committed an offence. In view of the seriousness of the offences which are committed against old and helpless people, I would not oppose that.
We are fortunate in the House in having a Minister for Health with legal qualifications, for I believe that parts of the Bill which deal with tribunals are those which can be understood and argued only by professional lawyers. The new tribunals are required to have legally qualified chairmen. My argument here is that there is no provision for at least one member to be representative of work people. Schedule 7, in paragraph 2, gives a wide discretion:The panel for an area shall be composed of persons appearing to the Secretary of State to have knowledge or experience of conditions in the area and to be representative of persons living or working in that area.522 My argument is that there should be employee representatives, and I think that the Secretary of State's discretion should be cut back.
I shall mention the advice from the Child Poverty Action Group because it is sound and because the hon. Member for Birkenhead (Mr. Field) was so signal in its achievements. It suggested that, rather than having a lawyer as a chairman, what was needed was a proper system of independent clerks not employed by the DHSS so that, just as magistrates do, tribunal members would have expert advice if they needed it. The Child Poverty Action Group lawyers argue that the more legally qualified people there are on tribunals, the more legalistic the tribunals will become. In any event, they will often be second-rate lawyers, because that is the only appeal of that sort of tribunal.
This is not a bad Bill. It should not be opposed by anyone who cares for people. Let us give it a Second Reading, let us get it into Committee, and let us try to make it into a better Bill.
§ Mr. Timothy Smith (Beaconsfield)
The hon. Member for Crewe (Mrs. Dunwoody) referred in her speech to the inquiry which my right hon. Friend the Secretary of State has recently set up to examine the management of the National Health Service. She was extremely dismissive of it and seemed to think that it was of no consequence. There can be no doubt but that there are real problems of management within the National Health Service and I, for one, very much welcome the inquiry.
I found interesting the exchanges on the Secretary of State's statement about trying to encourage health authorities to put certain services out to tender. There seems to be a complete failure on the part of the Opposition to understand that, if resources in the Health Service are limited, we must examine ways in which we can secure more economy, efficiency and effectiveness and greater value for money. If we can reduce the cost of some services without at the same time reducing the quality, there will be additional resources available for patient care.
The division of cost is about 30 per cent. on services which have nothing to do with medical or patient care and about 70 per cent. on the balance. If we could change that balance within a given amount of resources, it would be a welcome shift. Of course we should all like to see additional resources made available to the Health Service but it just will not happen at present. Therefore, I believe that the Government are right to take initiatives to see how we can ensure better value for money in the Health Service.
The right hon. Member for Norwich, North (Mr. Ennals) said that there had been no real growth; but over the past four years there has been considerable real growth in the provision of resources to the Health Service—more than 5 per cent. including, out of this year's provision, 0.7 per cent. The right hon. Gentleman said that all of that was consumed by the increase in the number of old people who make demands on the service. That is undoubtedly the case, but there have been real increases in resources over the past four years.
The right hon. Gentleman referred yet again to the Think Tank report. I wish to make my position on this absolutely clear. I wish to see the National Health Service remain largely in its present form. I want it to be a 523 universal service, but I want it to be made a more efficient service so that we get better value for money. The right hon. Gentleman extended this point by saying that the welfare state as a whole was under attack from the Conservatives. Again, I wish to make my position clear. I believe it is not under attack from this Government. The Government's record on pensions is good in a difficult period—I am referring not only to the recession but to the fact that the number of pensioners has risen substantially, by more than 500,000 since the last election. The Government have been able to preserve the real value of the pension.
The Bill has been described as a ragbag of measures, but it is none the worse for that. It may be difficult to make a Second Reading speech, as the hon. Member for Isle of Ely (Mr. Freud), who has just left the Chamber, said, but that is hardly an objection to a Bill if it includes a number of important provisions, as the Bill does. In particular, I welcome part I of the Bill, dealing with community care. I welcome its emphasis on encouragement for the transfer of patients and resources from the hospital service to community services. My hon. and learned Friend the Minister for Health, in introducing the Bill, mentioned that resources had been increased by 51 per cent. I think he was speaking in real terms. In fact, total expenditure in this area has risen from £33 million four years ago to £85 million in the current year, which is a substantial increase. I welcome that, too.
I welcome in clause 1 the extension of the law so that payments can be made for housing and educational purposes as well as for social services purposes. All the changes in part I of the Bill will be highly beneficial.
I have only one caveat about part I of the Bill with regard to the financial control and accountability for jointly financed projects, about which a report was recently made by the Comptroller and Auditor General. The hon. Member for Isle of Ely referred to this point when he spoke of the confusion over finance. There is some danger of confusion because if the objective is to transfer resources from hospital to community services we must ensure that this happens. In the report published in January, the Comptroller and Auditor General examined this area and said that in his view health authorities were not giving this the consideration that they should. He said thathealth authorities did not hold documentation showing that full consideration had been given to NHS as well as local authority priorities in a choice of schemes; or that there had been an evaluation of the objectives, likely costs and expected benefits to the NHS of schemes. Few of them had objectives set in terms of transferring patients from hospitals to the community. Further, health authorities did not obtain comprehensive information from local authorities enabling them to monitor the implementation of schemes and the benefits accruing to the NHS.There is clearly room for improvement in monitoring the schemes. If we are to commit additional resources, as we are doing, it needs to be considered by the Department.
Part II of the Bill deals with children and young persons. I very much support clause 3, which gives local authorities more autonomy over children's community homes. I have only one concern which arises from the inquiry by the Select Committee into children in care. There are three types of community homes—local authority homes, and two types of voluntary homes, controlled and assisted. The ideal provision in any local authority area is a partnership between local authority homes and voluntary homes.
524 We were therefore concerned to hear from witnesses who appeared before the Select Committee evidence that some local authorities are hostile to the voluntary sector. If there is hostility, in mail cases it is probably based on ignorance and on misunderstanding about what the voluntary sector can provide. Sometimes it may be based on ideological and political objections. If that is the case, it is much to be regretted. As my hon. Friend the Member for Lincoln (Mr. Carlisle) said, the voluntary sector has a major contribution to make.
Part III of the Bill deals with the Central Council for Education and Training in Social Work. Following an amendment in another place, there is included in the Bill clause 6(8) which provides:Grants for the training of social workers shall be mandatory and funded either by local education authorities or from central funds.I support the objective behind the subsection. We need a higher standard of social worker. The Select Committee will probably reach this conclusion as its inquiry into children in care develops. The quality of the provision of social workers is patchy. To some extent, their training involves too much theory and not enough practical work. I hope that clause 6(8) will be retained. I understand that the Government's only reservations about it are in regard to cost. Their estimate of the cost is widely at variance with that of the Association of Directors of Social Service, whose estimate is £2.8 million while the Government's estimate is apparently £13 or £14 million. The Government will have to consider that.
On part IV, which deals with residential homes, nursing homes and so on, the latest figures, which are for 1980, for residential homes covered by this part of the Bill show that there are 3,700 homes and 70,000 residents. These numbers are likely to increase substantially in the next few years. The existing legislation is in large part more than 30 years old and there is now considerable emphasis on physical standards as opposed to standards of personal care.
In answer to a question which I put down last October, the Government announced their conclusions in the light of the comments received on the consultative document, "A Good Home". I welcome the changes which appear in the Bill, and particularly the fact that standards of care will be set out in a code of good practice rather than in the measure itself. I disagree entirely with the right hon. Member for Norwich, North, who wanted these matters to be set out in the Bill. If they were, that would create a rigidity which would make it difficult in future to update the standards as the quality of provision changed. The matter should be dealt with in a code of good practice.
Part V, covering the organisation of the National Health Service, is the one part of the Bill where I am not as confident as the Government about the merit of their proposals. I listened carefully to what my hon. and learned Friend the Minister had to say about this part of the Bill. I understand and share the Government's objectives. I agree that we should try as far as possible in the Health Service to simplify bureaucracy, that we should try to improve efficiency and accountability and that we should help collaboration within the Health Service for the benefit of patient care.
I support the Government's objects, but I must put a question to them. The Royal Commission recommended that family practitioner committees should be abolished 525 and integrated with the health authorities. Would not abolition of family practitioner committees simplify bureaucracy? Surely that would reduce bureaucracy.
I cannot see how separation would improve efficiency and accountability. It might in certain circumstances, but we could apply the same argument to any other part of the Health Service and put that forward as a reason for separating that part. I am not aware, however, of any proposal to separate any other part of the Health Service, so that is a weak argument. I do not see how separation will assist collaboration. Again, special arrangements are proposed to improve collaboration, but abolition would inevitably improve collaboration.
Going back to efficiency and accountability, if the only way those aims can be achieved is by hiving off part of the Health Service, that is an indictment of the whole structure of the Health Service. What needs to be done is to make arrangements to improve efficiency generally throughout the Health Service.
I have that one reservation about the Bill. I shall listen carefully to what the Minister says later. With that reservation, I very much welcome the Bill.
§ 7.6 pm
§ Mr. Robert Kilroy-Silk (Ormskirk)
The most remarkable aspect of the Bill is not so much what it contains but what is missing. It would have been a wonderful opportunity to make important and fundamental changes in the law, many of which would have been welcomed by Members of all parties. For example, the Bill does not contain any provisions or proposals to reform the law, practice or procedure as it relates to children in care.
There is growing dissatisfaction with the law, with the procedures and with social work practice as they relate to children in care. There is an increasing number of injustices and scandals. The Select Committee on Social Services is examining the matter. From the evidence produced before the Committee, there seems to be a complete mess, with conflicting interests. The inquiry might perhaps be best undertaken by a Royal Commission. Certainly there must be a fresh examination of the practices, procedures and the law.
Problems arise because far too much power is vested in the hands of individual social workers and social work committees. I understand why that power was given to them. At the time it no doubt seemed sensible and reasonable to give enormous discretionary power to professionally qualified, trained social workers who would look after the best interests of the child and whose prime concern would be the welfare of the individual child.
I have endorsed, in principle, the welfare orientation, but, given its application in practice, and given the increasing number of anomalies, injustices and scandals, it is necessary to shift the balance away from the welfare model and from social workers to a judicial model and to the courts.
Parents and children want rights and they want to know what their rights are in relation to social workers and local authorities. They do not have rights. Social workers have far too much power and often act arbitrarily, making decisions for which they are not accountable. They are allowed to exercise almost unfettered authority over the lives of children and parents.
526 In the Bill we must move in two important directions. We must take away from local authority social service departments the power which they currently possess to impose parental rights orders and to take away from parents their rights over their children. That power must be vested instead in the juvenile courts. We must ensure that the parent and the child have the right to appear in court to be heard and to be legally represented. That is the only way in which we can redress the balance, which has gone too far in favour of local authorities.
At the moment, the social worker reporting to the social services department makes the decision, often in the complete ignorance of the natural parents. The local authority in effect assembles, collates, and provides the evidence. It cross-examines its officials in private. It acts as judge, jury and executioner. The parents' interests, if they are taken account of, are not properly represented where they count, which is where the decision is made.
It is indefensible for issues of human rights of that magnitude to be dealt with through administrative procedures. I cannot accept that, fashionable though it may have been a decade or more ago, and well-intentioned though the present legislation was, it is right and proper to take away the rights of parents and destroy the life of the child and its family by an administrative measure decided in secret behind closed doors. It cannot be defended. We now have the opportunity, which we must take, to change it.
The same applies to the present system of denying parents access to children in care. Local authority social workers who are responsible for children in care, voluntarily or compulsorily, have the right, which they exercise, as my postbag has demonstrated overwhelmingly, often arbitrarily, to cut off a parent's or relative's access to the child in care. The parent has no proper course of appeal to the local authority or any other organisation.
I have been overwhelmed by the horrifying accounts of the way in which children have been denied proper access to their parents. We must take that power away from unaccountable and irresponsible social workers and social work departments and bring it back to the full light of day in the courts. Those who suggest that that will in some way interfere with good social work practice are wrong. The social workers who are making the right decisions for the right reasons will have nothing to fear when their decisions are challenged, analysed, discussed and, presumably, approved in open court. Those who are making the wrong and inappropriate decisions will have a great deal to fear, and so they should in such a sensitive and important area as this.
We have the opportunity with which the Bill presents us to make a major fundamental reform in care practice by giving the courts the power, when a child is being taken into care, to determine what access that child will have to its parents and relatives and what access they will have to the child. They should have the power to impose a mandatory obligation upon the local authority to spell out to the court its proposals for renewing the access provisions for the family of the child. It should give the right to the child as well as the parents and relatives to go back to the courts at any time to vary the terms of the access order.
§ Mr. Timothy Smith
I have listened carefully to what the hon. Gentleman has said. I do not disagree with any of it. Is he suggesting that, while the Select Committee on 527 Social Services is considering the issues to which he has been addressing himself, we should legislate on those matters in the Bill?
§ Mr. Kilroy-Silk
The House does not wait for five or six members of a Select Committee to report, as the hon. Gentleman should know. I am a member of the Select Committee. I have never known the Government wait for its report. I have known them wait for the report but still ignore it. The Bill is before us. The House should grab the opportunity presented by the Bill with both hands and run with it. My right hon. and hon. Friends in the Opposition and, I think, some Conservative Members will take that opportunity in Committee.
Two other important issues have not been raised, which demonstrate the failings of the Bill. It could have been an opportunity for the Government to take legislative power to earmark Government funding for specific projects, which at the moment are regarded as national priorities but which do not get resources at local authority or health authority level. I am talking about intermediate treatment and services for drug abusers or misusers.
It is generally acknowledged that intermediate treatment should be central to any policy for dealing with juvenile delinquency. The system has been encouraged increasingly by the Government. In intermediate treatment, there is counselling for and constructive work by young people in the community, who acquire skills and become positive contributing members of the community instead of juvenile delinquents. The system works. We know it works on the grounds of cost, because it costs about £100 per child per year up to, in the more sophisticated schemes, £2,000 to £4,000 per year. That is a lot of money, but it is only a little compared to the alternative of £10,000 per child per year in a local authority community home, £9,000 in a borstal or £8,000 in a detention centre. The system works on that basis.
The system also works on the girls and boys who would otherwise have been given a custodial sentence and gone to borstal or a detention centre. The intermediate treatment schemes catering for that clientele are producing recidivist rates of about 35 per cent., which is considerably less than the 83 per cent. in detention centres or the 76 per cent. in borstals. However, only slightly less than £12 million in the current financial year is being allocated to intermediate treatment as opposed to the £197 million that is being spent on local authority community homes with education, observation and assessment centres.
The other schemes are variable in their sophistication and the constructive approaches that they provide. They are also patchy in their distribution, with, for example, 10 per cent. of local authorities taking well over 36 per cent. of the total budget that has been allocated.
I know that the Government are giving active support and encouragement to the establishment of further intermediate treatment schemes. I acknowledge that the Government gave an extra £2 million under the Criminal Justice Act for intermediate treatment schemes to be set up. However, they must acknowledge that there is no certainty that local authorities in receipt of the money will use it for the purpose for which it is intended unless the Government take powers, for which the Bill provides the opportunity, to earmark the money specifically so that local authorities cannot use it for other purposes.
The Minister must acknowledge that in the absence of those powers local authorities receive the money and use 528 it for other purposes. There are no votes for the setting up of intermediate treatment schemes. When they are in competition with higher priority services provided by local authorities, they inevitably lose. As a result more young people get into trouble and are shovelled off into the social dustbins of local authority community homes or penal establishments. Precisely the same arguments apply to the services for drug misusers.
§ The Under-Secretary of State for Health and Social Security (Mr. Tony Newton)
I am hesitant to intervene, but I am not clear from what the hon. Gentleman has said that he has registered the fact that on about 22 January—certainly quite recently—the Secretary of State announced a £15 million programme over the next few years specifically earmarking money for new schemes by voluntary bodies, sponsored by local authorities, for intermediate treatment.
§ Mr. Kilroy-Silk
I have not overlooked that. I omitted to mention it because I am trying to rush through my speech. If the hon. Gentleman is to quote what his Department is doing, he must get it right. The £15 million that his right hon. Friend announced for intermediate treatment is not for one year, but for five years, so it is a small amount of money and is still insignificant in relation to the £197 million that goes on community homes with education, observation and assessment centres.
The £15 million is not earmarked for a specific purpose. The Secretary of State would like it to be spent on intermediate treatment, but he has no powers at the moment to insist that that is the way in which local authorities will use it. That money is going not to local authorities but to voluntary organisations. No doubt we shall argue about that in Committee. The principle is the same. If the Minister's point is valid, why is there such an enormous variation in the provision of intermediate treatment? Why do some areas have it and some not? Why do some areas have extensive comprehensive schemes and others patchy and superficial schemes? The answer is that there is no central financial control.
Precisely the same problems arise over the facilities and services for drug misusers. The Minister will know that the advisory council on the misuse of drugs, in its report on treatment and rehabilitation, published in December, pointed to the dearth of facilities for drug abusers, to the inadequacy of services in many areas, to the fact that those services were overburdened and that an increasing number of drug abusers were imposing strains on the already overstretched services.
The report also said that the voluntary organisations, which are so important in this field and which have been so much lauded by hon. Members this afternoon, are doing a magnificent and important job under considerable pressure, while spending most of their time fund-raising rather than meeting the needs of drug abusers at the sharp end.
Again, the problem is lack of resources. Services for drug abusers are being provided by local health authorities, but because there is no obligation on them to do so, and no central funding, the services that they provide differ markedly from one area to another. There is no standard of provision. There is no uniformity. Therefore, we end up again with a patchy network of services and in areas such as Cumbria, the home counties and the north midlands there are no clinics at all for drug abusers.
529 There are 20,000 opiate and barbiturate addicts in Britain and only 229 places in rehabilitation hospitals and only seven off-the-street agencies in five cities. Massive areas of Britain are completely bereft of any services for drug abusers and misusers. Whole areas of Britain have only the services of the general practitioner. If we are to meet the needs of an increasing number of deprived, disadvantaged and vulnerable individuals, it can be properly done only if the Government are prepared to take powers to provide resources which are specifically earmarked for the provision of that service at a local level.
Drug abusers, like juvenile delinquents, do not generally have a great deal of political clout or leverage. They do not get resources because they do not have votes and they cannot compete with the more attractive facilities of maternity or kidney units. Therefore, their needs are neglected and left behind. Unless we are to have more drug abusers in greater difficulty taking up crime and ending up in the penal system, the Government must ensure that funds are available and specifically tied to those facilities.
I hope that we shall be able to improve the Bill in Committee, to change fundamentally and radically the law as it affects children in care and to provide, in at least two areas, and perhaps in many others, proper finance and services for some of the most disadvantaged and vulnerable of our fellow citizens. It will then be a Bill of which we can be proud.
§ Mr. Mike Thomas (Newcastle upon Tyne, East)
The discernment of principle in the Bill is rather difficult. As Second Reading debates are supposed to be about whether hon. Members support the principle of a Bill, I share the difficulties of those who have said that it is extremely difficult to avoid degenerating into Committee points. As I do not want to do that, I shall make a brief and, I hope, constructive speech.
First, I should like to clear up any misapprehension on the Conservative Benches as to the Social Democratic party's attitude to the Bill. We shall support the Bill and not seek in any way gratuitously to obstruct its passage through the House. We welcome it in the main, although without great enthusiasm, and we share the concerns of those hon. Members who have already pointed to omissions and deficiencies. However, it is fair to say that those are not such as would prompt one to embark on a criticism of the Bill in principle. Indeed, part I will enable health authorities to support housing and education expenditure, and we welcome the fact that it will make joint financing more flexible. We do not want to make a great fuss about that.
One omission I refer to is more because those who have gone before me have done so than because it relates directly to the Bill. It is certainly the case that a move to implement the Greenfield report and extend the practice of generic substitution of drugs, common in most NHS hospitals, to community pharmacies would make substantial resources available to implement the objectives that the Government claim are behind the Bill. I find it a little hard to be lectured on the topic by the right hon. Member for Norwich, North (Mr. Ennals), because when he was Secretary of State I and other hon. Members lobbied him and his Minister of State, the right hon. Member for Lewisham, East (Mr. Moyle), and we had no 530 response at all and no movement in the direction towards the position that the Labour party has now somewhat belatedly come to occupy. Any legislative change that is needed to implement that provision certainly could and should be contained in the Bill and would make a welcome financial contribution.
My second point concerns primary care systems and, in particular, the family practitioner committees. When the Minister opened the debate, he was kind enough to allow me to intervene several times on this topic. I am grateful to him for that, because it means that I do not need to labour the point now. However, let us be quite clear. We know, because the noble Lord Trefgarne was kind enough to write to the noble Lord Kilmarnock to tell him so, that the claimed support of great battalions for the change that the Government propose in the status of family practitioner committees is based on the supposition that 56 per cent. of those who made representations about the proposal were in favour while 44 per cent. were against. In that letter the noble Lod Trefgarne, no doubt inadvertently, did not make clear which representations were made in which direction.
I referred earlier to vested interest. It seems to me that it is natural and not all that sinister that those who are involved in the functioning of the family practitioner committees at the moment should want to sustain an independent status and not want to be integrated into the district health authorities.
There may be general practitioners who feel, in my view erroneously, that their independent contractor status might be threatened by the incorporation of the family practitioner committee into the district health authorities which have influenced some professional bodies in that direction. Who knows? It is hard to tell. All I can say is that the move does not seem likely to save money or to allow primary care to be better organised than under the alternative proposal, which is to integrate the family practitioner committees into the DHSS to turn them into primary care committees of the district health authorities. If the only case that can be advanced for the Government's proposal is that 56 per cent. were in favour, that is a weak case indeed. I hope that we shall be able to return to that in Committee and that Conservative Members who have taken the same view on this matter will serve on the Committee and perhaps help to change the Government's mind about it. That would be the most important improvement that we could make to the Bill, and I hope that it will be made.
However, I agree with the Minister that that is not a matter of such moment that we should want—as I gather the Labour party does—to vote against the Bill. That would clearly be nonsensical—but it must pursue its nonsensicalities. I hope that the Government will not seek to reverse clause 6(8) which deals with mandatory grants for certain kinds of social workers' training. It seems a useful contribution to the Bill by the other place.
We shall not obstruct the Bill. We believe that it can be improved. Our specific difference is with the proposal for family practitioner committees. No doubt there will be other Committee points that we can take up subsequently. We wish the Bill well.
§ Mr. Tim Sainsbury (Hove)
I hope that the hon. Member for Newcastle upon Tyne, East (Mr. Thomas) will forgive me for not taking up his points about generic 531 drugs and family practitioner committees. However, I am glad to support the Bill and his comments about the Labour party's attitude to the Bill, which were borne out clearly by the speech of the hon. Member for Ormskirk (Mr. Kilroy-Silk), who spoke about what would happen in Committee, but started with a rather grudging statement that he was opposing the Bill, not because of anything it contained but because of what it did not contain. I agree with the hon. Member for Newcastle upon Tyne, East that that is a nonsensical attitude.
I support the view of the hon. Member for Ormskirk that there are genuine grounds for anxiety about parental access to children in care. Like him, I have constituency cases where it is difficult to make a judgment, but one is left sometimes with the suspicion that, with the best of intentions, county council social services have leaned away from providing parental access. They have not even encouraged the child to respond to letters or keep in communication with parents. Occasionally they have taken the child into care a little too readily.
We are aware of the distressing cases that have occurred in my part of the country, but it is necessary to strike a balance. I am not sure that the hon. Member for Ormskirk was right when he suggested so much access to courts, but it is a matter to which the Government could well direct their attention and there will perhaps be more detailed discussion about it during the Bill's passage.
I want to direct my remarks to part IV, which is perhaps not altogether surprising as I represent Hove where we have no fewer than 72 private homes for the elderly providing 800 beds and a further seven local authority homes providing 322 beds. I do not know whether we are at the top of the league, but we must be near the top, for the residential care premises with which part IV deals. In my constituency there are many elderly senior citizens, the vast majority of whom live in the community and not in residential premises.
East Sussex county council has some imaginative schemes which are proving extremely effective in providing help to the elderly in the community, in particular, the intensive domiciliary care scheme which I hope we shall see extended throughout the country. It appears to be a more cost-effective way of providing greater help to those who are frail and at risk in the community than the traditional home help scheme. There are several parts of the Bill which will help those who are not living in residential care premises.
I welcome what is set out in part IV about residential homes. I was somewhat amazed and rather disappointed at the attitude of the hon. Member for Crewe (Mrs Dunwoody), who spoke for the Opposition, to this and every other part of the Bill. It seemed to reflect what has become, unhappily, the traditional Labour party attitude to the NHS and the personal social services. They seem to approach the NHS with the feeling that the system should be run for the benefit of the staff rather than the patients. If anyone suggests anything which might be a way of providing a more efficient and cost-effective service, or of improving the service, which might be seen in any way as infringeing what the unions would like, the Labour party is wholly against it. The patients' view—the value-for-money approach—does not seem to figure at all. I hope that the Government will continue their search for ways to improve the quality of the service to the patients and to provide better value for money.
532 I welcome today's announcement about the contracting out of certain non-medical services. I know of no better way not just of improving the quality of services—we must all know of NHS premises where the food is not perhaps all that it might be—but of providing some measure against which one can test the performance of particular hospitals: whether the in-house or the contracted-out service provides a better performance, standard and value, which is what we should be seeking.
I welcome also the management study that is being conducted. I thought that the attitude of the hon. Member for Crewe to it was nothing short of disgraceful. She seemed to assume that management was a speciality and that unless one was born, bred, brought up and spent one's life in the National Health Service, one could not possibly be qualified to express a view on the NHS management structure. It shows an astonishing ignorance of management. The Health Service management, which is being looked at, is the management of administrative functions which are common to businesses in the public and private sectors.
I should have thought that anyone who had any experience of the Health Service would have been prepared to agree that there was considerable scope for improving the management expertise which is brought to bear upon the non-medical functions in the Health Service. By improving that management, we shall improve the quality of the service to patients and produce savings which might then be used to provide better services for those most in need. Surely that is what we should concentrate upon. In that context, I believe that the approach of the hon. Member for Crewe to the Bill and the management survey was extremely disappointing.
§ Mr. John
The hon. Gentleman should be so lucky, is my only comment. I shall put to the hon. Member for Hove (Mr. Sainsbury) the fundamental misconception which many of his kind bring to this subject: running a business is not the same as running an industry which cares for people, because the end result is different. The firm of the hon. Member for Hove wishes to maximise profit; we want to maximise public good. Often the best and most efficient way of managing the Health Service is to ensure that the managers take the time and trouble to explain to often bewildered patients their rights and what is being done for them. That does not happen in the private sector.
§ Mr. Sainsbury
Of course, the hon. Gentleman is right. One has to deal carefully with bewildered, ill, elderly and frail patients, but it does not mean that one cannot see whether the laundry, the catering, the cleaning and the administrative paperwork is being done as efficiently as it could be done. The qualities required to ensure that are exactly the same in the public and private sectors.
One will succeed in the private sector, in whatever form of business, only by providing good value for money and what the customer wants. That is never more trae than in retailing. It can be done only by being efficient and by bringing to bear the analysis of the service that the customer wants in the most efficient way. Surely that is what we are seeking with regard to the NHS.
§ Mr. John
The hon. Gentleman cannot get away with that. He attacked my hon. Friend the Member for Crewe 533 (Mrs. Dunwoody) on the ground that the qualities which managers bring to private business are exactly the same as those needed in the NHS. He is now saying that they are not, but that the laying out of the biscuits might be roughly similar.
§ Mr. Sainsbury
We run the risk of operating a parallel debate which would be wrong. The management of people and administrative services is common to all types of business. I do not believe that it is being well done in the NHS. It should be done better, and when it is not only will there be better service for the patients, but we shall obtain better value for money and release resources to where they can be used more effectively.
I welcome the convenience and clarity of having all the relevant provisions for registration and inspection of residential care premises set out in part IV. It is convenient both to those responsible for inspection and registration and to the owners of those premises. I am especially glad that it will become mandatory to have at least one inspection a year. Some hon. Members have said that that is not enough, but all of us recognise that in many homes even one inspection would be superfluous. I do not say that there should be no inspection, but the local authority will know the quality of the management and the service provided and will expect to find a thoroughly satisfactory position. It will not need to worry about revisiting the premises in three or six months. However, authorities can make more inspections in premises where they have reasonable cause for doubt, and I hope that that will take place.
I welcome the increase in penalties for operating unregistered premises. That will be an assurance to many people who have parents, grandparents and other relatives in homes, because sometimes there is suspicion that registration does not mean much, that the premises are not registered or that the premises have declined in standards since registration, and that inspection is not taking place. The provisions will be a worthwhile safeguard and will help to bring up the standards of the poorer homes to those of the better.
I disagree with the hon. Member for Crewe—who is not present but who is ably represented by her self-confessed surrogate—that we should try to write into the Bill detailed standards covering the staff numbers required in residential care premises. That is unrealistic, because there is a widely differing range of circumstances in homes. Some provide nursing care while others provide only residential care, and the incapacities from which residents suffer and the care that they require often differ. To try to cover those matters in detailed provisions is impractical and would lead not only to inflexibility but to an incredibly long Bill.
The hon. Lady also suggested that the Bill should include standards for fire precautions. I welcome the belated publication of the code of guidance on fire precautions in residential premises which was published by my right hon. Friend the Home Secretary. It is comprehensive and I am sure that it will be of great assistance to local authorities in carrying out the inspection and registration of premises.
I ask my hon. Friend the Under-Secretary of State two questions. When will the code of good practice be available, because that will be very important? I hope that 534 it will not be too long before it is available to help both the operators of premises or those responsible for inspection. Will members of the community health council also have the right of access to and inspection of premises? If not, in what circumstances will it be open to members of the community health council to inspect premises?
I regret the fact that the Labour party will vote against the Bill tonight. Labour Members seem to be more interested in scoring political points than in care in the community. However, I welcome the opportunity that they provide to show my support for this worthwhile Bill by voting for it this evening.
§ Mr. Frank Field (Birkenhead)
It is easy to follow the contributions that we have heard tonight because I, with them, find it difficult to make a speech on Second Reading of the Bill. The Minister understood our difficulties earlier when he described this measure as a dog's breakfast. He said that he hoped that we would not vote against the measure because it is uncontroversial. If it is so uncontroversial, I hope that he will come to the Committee with an open, but not an empty, mind and consider carefully the suggestions for improvement that we put forward. He would be well advised to do so, because the hon. Member for Canterbury (Mr. Crouch) seemed to map out the ideal way for a Government supporter to deal with his Front Bench when he disagrees with a measure. With considerable generosity of spirit, the hon. Gentleman paid tribute to the Minister's abilities and then tossed him an argument which, despite those abilities, the Minister was unable to answer. I hope that the Minister can answer those arguments and others that may be put forward tonight and in Committee.
The Bill has a long title—"Health and Social Services and Social Security Adjudications Bill"—but one way in which we shall judge the effectiveness of the measure is to see how it matches the needs of our constituents. Although we may criticise the absence of some proposals from the measure, it is important to say that many of its provisions will affect not just hundreds but thousands—perhaps tens of thousands—of the people we represent. It is therefore a crucial measure, and I shall address my remarks to three areas of the Bill—the reform of the tribunal system, the clause that deals with some charges and the schedule that provides for co-operation between different authorities.
The Minister rightly drew attention to the importance of what he called the tribunals of the social services. It would be more apt to call them the courts of the welfare state, because for most of my constituents—unless they have caught something off the back of a lorry and been caught themselves, or if they have a matrimonial dispute, or if they have thumped someone on the head—disputes are settled not in the magistrates court or the county court, but in the courts of the welfare state. This is where the big decisions that affect their well-being and livelihood are made.
The Government are addressing themselves to that area of adjudication. They say, with some justification, that if one considers the different tribunals that already exist, the tribunal that comes off least well is the one in the supplementary benefit system. The solution has been to examine national insurance and industrial injury tribunals and to ask, "What can we learn from these tribunals to improve the other tribunals of the welfare state?" The 535 ingredient that they have come up with is the lawyer. But are the Government asking the right question? Will the qualities of lawyers make a difference to the adjudications of supplementary benefit appeal tribunals, which will be merged into more general tribunals, or do we need lawyers because we do not have an effective system of clerks to advise chairmen and members of tribunals on the law and the regulations?
One weakness of the supplementary benefit appeal tribunal is that the clerks, although good people, are on loan from the Department of Health and Social Services. They know that they will return to the DHSS and that that is where most of their career opportunities lie. It therefore takes someone of considerable ability and courage to stand out and rough up his employer, especially when his employer will make the big decisions about how fast, if at all, his promotion takes place.
Therefore, the first thing that I should like to put to the Government is this. By all means let us have more lawyers and more legal skills in the new tribunals—the Minister has a touching faith in lawyers; perhaps understandably so with his training—but we would make much more important advances in the courts of the welfare state if we had a career structure for the clerks of the tribunals. They could be interchangeable one with the other, and not be dependent upon going back to the DHSS to make a career. They could achieve all of their job satisfaction in, for example, the appeal tribunal system.
It is a matter not only of the quality of the decisions and of the adjudication in the tribunal, but of how quickly one gets to a tribunal hearing. It does not matter too much if one is on a driving offence and one waits five weeks, five months or five years before the case is heard. However, if one is dependent on benefit and has no other money, it is crucial that one's case is heard quickly.
I have been corresponding with the Minister and, in one of his replies to the House, he said that he was concerned that the waiting time to appear before a court has doubled. For many of our poor constituents that means waiting many weeks for benefits that are crucial to them. I can give some examples of what that has meant to my constituents, and these show what no doubt happens to many other constituents. My first example concerns a single claimant who acquired his own home and was waiting for a single payment to furnish his home. However, it was eight weeks before his case was heard and he had little furniture and no cooking equipment. As a result, he lost 2½ stone while waiting for his case to be heard in one of the courts in the welfare state.
Another example concerns a family in my constituency who waited a similar time for a single payment for beds. Until they got that payment, the husband, wife and two children had to sleep in one bed. That is what waiting means. It is much more important in the courts of the welfare state than elsewhere. Introducing lawyers will not speed up the process. I hope that the Minister will have something to say about streamlining the hearing of cases.
There is also the issue of pooling abilities and knowledge or, in the words of the Bill:The co-operation between local authorities, Family Practitioner Committees and local authorities".I make a plea on behalf of some of my poorer constituents that these consultations should include someone with knowledge of welfare rights. For many of our constituents, this is where the shoe pinches. I am lucky, as is my local council, that in Birkenhead, thanks to the funds given by 536 the Joseph Rountree charitable trust and the Gulbenkian foundation, a lawyer works with the Member of Parliament and the councillors. The lawyer has made a submission to the district health authority, and it is from that submission that I draw a suggestion for the Minister. We are lucky in Birkenhead in having perhaps the most talented welfare rights lawyer in the country working on our behalf—Nicholas Warren.
Mr. Warren has pointed to areas of crucial concern to an ever growing number of our constituents. One is the problem of getting to a hospital. A previous Government issued a circular about travelling expenses to hospital which said how important it was that there should be notices all over the hospitals about people's rights to financial help in getting to the hospital, and one place in a hospital where money is paid out to cover fares.
The effect of not having fares is illustrated by two cases. One concerns a woman who was six months pregnant. As she was having difficulty with her pregnancy, the doctors wanted her to attend the clinic more often. She did so, although it cost her a great deal of money in fares to get there. Her husband was unemployed. Because she had to pay all that money on fares, she cut down on her diet. We all know the importance of adequate diet to a pregnant woman. Without information about fares being put over, many of cur poorer constituents will lose out.
Another example concerns a widow in my constituency. The doctor thought it essential that she should attend the hospital. When he learnt from the hospital that she had not turned up for her appointment, he inquired why. Her explanation showed the choice that many of our constituents have to face. The day of her appointment at the hospital was the day before her benefit was due, and, like so many of our constituents living on benefit who are not fiddling, there was no money left. Therefore, she could not afford the fare to go to the hospital. When talking about co-ordination between different bodies with an interest in health, it is clearly important to link in the welfare rights advisory expert or officer in the locality.
Clause 12 deals with contributions for children in care. I am pleased that the Government have accepted an amendment in the other place, although, from what we have learnt today, we do not know whether the Government will stand by amendments agreed in the other place. I hope that they will on this one. The Government laid down which groups of our constituents will be exempt from making contributions for their children in care. Some may say that that is not terribly important, but it is important if one's children are in care and one is on benefit.
By laying down that those in receipt of family income supplement or benefit should not have to make contributions towards the cost of their children in care, the Government have made a useful advance. However, I ask them to go a stage further and, in Committee, to amend the amendment. We know, for example, from the reply of the Minister's predecessor that only half those eligible for benefit are claiming. There will be large numbers of people whose income is around the FIS level who could be eligible for, but are not claiming, benefit.
We also know that 100,000 claimants on invalidity benefit can never get on to the long-term supplementary benefit rate and sometimes cannot even claim the short-term supplementary benefit. Under clause 12 as it stands, both those groups, whose income is at or below the level 537 in the amendment, would have to pay contributions. I ask the Minister, in my rather detailed Second Reading contribution, to extend the amendment further to cover those on incomes around the level of those on supplementary benefit and those eligible for FIS.
The Bill, as it stands, is useful for many of our constituents and it will become more useful when, I hope, the Government allow it to be amended in Committee. However, one has to compare it with what is needed from a measure like this, given the needs in the community as a whole. Let us look at the numbers of poor people in our society and take as a starting point the general election. If we take that as a cut-off point and measure how the numbers of poor have grown under the Thatcher Government, we find that the numbers claiming supplementary benefit have risen by 67 per cent.
The numbers of children in poor families have increased by 91 per cent. Well over 7 million people now depend on supplementary benefit. Probably 2 million more are eligible for, but are not claiming, it. A huge tidal wave of poverty is sweeping through many constituencies. Against that background, this is an inadequate measure. One almost thinks of those who tried to deal with the crisis on the Titanic by baling out the water with tea cups. It was no doubt a useful occupation to avoid facing the awful truth, but in the end it was not much help to those who went down with that great liner. Equally, for those of our constituents sinking in the tidal wave of poverty, this Bill will do very little.
§ 8 pm
§ Mrs. Renée Short (Wolverhampton, North-East)
Having been here since the beginning of the debate, I am concerned at the amount of undiluted criticism—a stronger word might be more appropriate—by almost every Conservative Member who has spoken of those who I believe serve the Health Service and social services extremely well. The administrators, in particular, seem to be everybody's butt. From the Secretary of State to the grocer, everyone had a go at them. That is a thoroughly unproductive form of argument. Those of us who know the National Health Service and are in touch with the hospitals, the adminstrators and all who care for the patients know that they serve their hospitals and their patients very well indeed. The Government's attempt to shift the burden of responsibility for their own shortcomings in that way does not go down very well with Opposition Members.
As the House probably knows, the Select Committee is at present examining certain areas of child care. As my hon. Friend the Member for Birkenhead (Mr. Field) said, the Minister referred to the Bill as a "dog's breakfast". It is certainly a mixture and it is difficult to pick out the areas of interest with which one wishes to deal. I shall concentrate on those aspects at present being examined by the Select Committee. We rapidly learnt that this was a complicated area of legislation, with a large number of omnibus Acts already in operation. All that legislation requires examination and streamlining—a task which the Bill does not claim to tackle at all. I do not know how long it can be postponed, but some day some Government will have to undertake that colossal task.
The Select Committee has had the opportunity of hearing a number of witnesses, both individuals and 538 organisations, and we have already visited two regions. It is always interesting to talk to the people actually doing the job. One gets a very different picture from that so often depicted by the Government. We visited two regions to see how children were being cared for by social service departments and social workers and the provision that is made when home is no longer an option.
Clause 3 proposes the abolition of regional planning committees, and I agree with that, as I do not think that it is necessary now to have such large committees. The clause will not prevent local authorities from co-operating with one another and working together if they so wish. It is always good to see obsolete layers of administration removed, although it does not often happen.
London is rather different, as in many areas there is a need to share services and facilities provided by one authority or another. For example, the 32 London boroughs may well wish to share regional specialist facilities. The trend is, however, for some resources and activities formerly organised on a regional basis to be provided by the boroughs themselves. Observation and assessment come to mind as examples. There are community homes where education is provided by the local authorities. Those remain a valuable facility and are not to be closed without the approval of the Secretary of State.
Clause 6 provides for the reduction of the Central Council for Education and Training in Social Work from the present 64 members to 25. Personally, I do not object to that. It was a very large, cumbersome committee and the chairman must have had considerable difficulty at times in controlling his flock. I also think that large committees tend to be rather useless and unwieldy and to talk too much without reaching decisions. I may be misjudging them, but I always feel that a small committee is more efficient. Decisions can be made far more quickly and sensible proposals can be put forward and implemented. I therefore support that proposal.
The Secretary of State will need to ensure that the streamlined council is truly representative of all those concerned with the need to ensure effective training for social workers, including those who employ social workers and who at present feel that their views are not adequately taken into account by those who run some of the courses.
We are aware that there have been problems for social workers. Clause 6(8) concerns mandatory grants for the training of social workers. Several Opposition Members have referred to what I suppose will go down in history as Baroness Faithfull's amendment. Like my hon. Friend the Member for Birkenhead, I hope that the Government are disposed to keep that in the Bill. It seems invidious that social work should not be included in the list of mandatory awards by local education authorities. The Association of Directors of Social Services has been pressing for that for some years. It is therefore very important that that proposal should remain in the Bill. Other three-year university courses providing a certificate or diploma are included, a whole list of courses having been approved by the Secretary of State. Some international courses also qualify for mandatory grant. It is therefore only sensible that training for social work should qualify as well.
I am very concerned that at present local authorities are free to appoint persons without qualifications and even without much experience in social work to posts requiring a great deal of contact with claimants and with people with 539 severe difficulties of the kind we all meet at our constituency surgeries. Strong words have been used recently about this. I am sure that the Minister is well aware of the Department's own report, "Child Abuse—A Study of Inquiry Reports 1973–1981".
In the report, attention is given to the level of training of staff who were the subject of the various inquiries that took place in the 1970s. The report quotes from the Maria Mehmedagi inquiry published in 1981 as follows:We were surprised to find how little training the people most closely involved in this case had received".A more recent report into the Gates family, published only about seven or eight months ago, makes the point:It is surprising therefore that it is not a requirement of professional workers entrusted with the care of children that they should have had specialist training in child care and the recognition of child abuse".This is a serious condemnation of the present system. I understand that the London borough of Bexley, which commissioned the report on the Gates family, in an advertisement appearing in Social Work Today on 26 October sought for its children and adults division asocial worker qualified or with relevant experience".The advertisement stated that the person appointed would beworking primarily with families and children; some mental health duties involved".That is scandalous. It seems that some of these authorities never learn. I think that all local authorities should now insist that trained social workers are appointed. I understand from the council responsible for the training of social workers that there is no shortage of trained social workers. Large numbers are being trained. This is a serious aspect, which the Secretary of State should investigate.
If hon. Members have any doubts, I ask them to reflect on the large resources, in terms of man and woman power and capital and revenue, that social workers are engaged in administering and recommending to claimants. This is apart from the work that they perform for so many people of all ages in need of care and help. Clause 12 makes amendments to local authority charges for boarding and gives certain exemptions. I question whether the Bill should be bothering about this nit-picking over charges. Parents of children in care should not be charged. Many of them are families in poor circumstances. I hope that the Standing Committee will decide to eliminate the charges. The time, cost and effort spent in collecting the money are not worth the trouble. The whole exercise is counterproductive.
Some improvements appear in paragraph 8 of schedule 1. It is acceptable that refusal to allow visiting or a medical examination can lead to place of safety procedures. Paragraph 7 gives protection to a child likely to be a member of a household where a person has been convicted of certain offences. The paragraph is intended, I understand, to protect the child against certain abuse from a member of the household. That provision will, I believe, be acceptable to all hon. Members. Paragraph 11 provides that children over five need not be brought to court in person on application for an interim order if legally represented. If a parent is accused of injuring the child, there will be no confrontation in court. On the other hand, the views of the child must be considered. Even small children, perhaps including those under five, must somehow be consulted and should be able to express views that would be made available to the court.
540 The Select Committee is embarked upon an examination of parental rights and access. These are matters of considerable importance in child care. We shall be making our recommendations in due course. The whole issue of child care is complex and unstructured. The recommendations that we shall make will benefit from the fact that we have been able to meet directors of social services and social workers. We have been able to talk to social workers in some depth to find out their reasons for embarking upon a career in social services. We have also had interesting sessions with some of their clients both here and in Bradford. We have met young people aged between 16 and 18 who have spent a considerable time in local authority care. We have been amazed at their resilience in the face of the experiences that they have had to go through. Their maturity has surprised many hon. Members.
We have been greatly encouraged by the experience of these young people in community care. The opportunity to talk to those on the receiving end who endured such appalling experiences when they were tiny is a considerable recommendation for the care that they receive from social workers and the local authorities which run the accommodation where they have spent such a large part of their lives.
I hope that we shall be able to proceed with our report. I do not suppose that the Standing Committee will still be sitting by the time that we finish.
§ Mrs. Short
I hope not, for the sake of hon. Members serving on the Committee. I hope, nevertheless, that the report that we produce will help the Government or their successors in the reorganisation of the administration and of legislation in this area, which is obviously necessary.
§ Mr. Andrew F. Bennett (Stockport, North)
Like my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short), I regret the fact that the Government and most of their supporters have spent much of today knocking the Health Service. The Government should start to think how they can get the best results out of the Health Service. If the Minister had spent time consistently and regularly praising the exceptionally good work done in the Health Service—not only that of the doctors and nurses but of all those who work within it—the Government would obtain far better results from the service. Every time I visit a hospital, especially some of the older buildings, I admire the remarkable job performed by those who work in the laundry. That is a job that most people would not wash to do. We should praise them for work of a high standard.
It is the same story when one considers the catering services in hospitals. Many people believe that it is simple to provide meals in a hospital. To a certain extent, it is a matter of producing a large number of meals. However, in good hospitals, increasingly catering forms part of the patient's treatment. A great deal of skill goes into planning a diet that will improve the patient's health. There is a wish to encourage the patient to eat the food. In many hospitals, that function is carried out extremely well.
I should also like the Minister to take account of the cleaning and portering services in hospitals. Those who carry out the cleaning tasks can contribute a great deal towards making the hospital a friendly place with a 541 pleasant atmosphere that can do more to improve the health of patients than the efficiency with which they clean the floor. Even those running large supermarkets are concerned about the atmosphere as well as the amount of floor space to be cleaned.
The Bill is inadequate measured against the basic needs of the country. If hon. Members visit any constituency in the country—not only the deprived areas—and witness the lack of facilities for good health and good social services and the obvious poverty, they will realise that this is a disappointing measure.
When we turn to the financial provisions at the beginning of the Bill, we see that there will be no additional public expenditure. Indeed, small savings in administration costs will result in a net saving of about £2 million. We get the feel of the financial provisions. The only expensive area is that to which the other place directed its attention. There is an argument about how much money is involved. The directors of social services suggest that we should be talking about £2.8 million, which is slightly less than the financial provision that it is suggested the Government are trying to save.
This is very much a hotch-potch measure. Tribunals and adjudication are major areas of concern. I agree with my hon. Friend the Member for Birkenhead (Mr. Field) that the process needs to be speeded up. My hon. Friend said that one of his constituents had to wait eight weeks for an essential needs payment for furniture. I have a constituent who applied for that grant before Christmas 1981. His application was refused. The appeal was not heard until March of last year. An appeal on a point of law is now outstanding. The commissioners have agreed to hear it in March of this year. The procedure has taken over 15 months and my constituent is still without a bed and other furniture to put into his accommodation. That is unacceptable. The whole system needs speeding up. If I were convinced that the process would be speeded by these changes, I would be much happier with them. I have pressed the Minister on this issue on many occasions. Many cases that go through the adjudication process do not need to go through it.
It is argued that when a claim for a benefit is made out of time there is a necessity to ascertain whether the applicant has been ill. Many claims are disallowed because they are out of time where there can be no argument about the facts. I hope that the Government will resolve the difficulty of out-of-time claims so that there will not be many appeals. I am assured from Stockport that many people appeal because they have been turned down for being out of time and then do not bother to attend the tribunal.
Many people do not attend the tribunals because they are put off by the process—they find that they cannot get anybody to represent them or are unable to get adequate information. If the tribunals are to be reformed, we must make sure that people have help with representation. It is regrettable that the Government's almost paranoid attack on the trade unions is carried to the level of dispensing with the panel that was drawn basically from the trade unions. The Government should look at that again. The majority of people believed that they would get fair play because there was someone on the tribunal who they thought would look after their interests.
542 I am concerned about the Government's enthusiasm for having lawyers as chairmen. The basic essential of a chairman is that he should be someone who will get a claimant to put forward his case and will not be put off by legal jargon or legal processes. My experience is that lawyers are not always the best persons to put an individual at ease or to ensure that his case is fairly heard.
The Department of Health and Social Security is one of the few Government Departments whose officials can represent it in the courts. It claims that the issues are so complex and technical that lawyers are not to be trusted with its cases. It is one of the few areas in which non-lawyers can appear in the courts. To suggest that a lawyer is the best person to chair a tribunal is doubtful. Many people other than lawyers possess the skills and qualities to be chairmen. There is a need to move in that direction. There is a danger that the panel will increasingly be drawn from people who will be seen to be middle class in attitude, and that will not please many of the claimants.
I am concerned about the question of the family practitioner committees. I do not believe the independent role will improve matters. I find that the disputes about the Health Service in my constituency tend to be between a doctor who believes someone ought to be admitted to hospital and a hospital consultant who says that he has not a bed for him or that admission is not necessary. Having two independent bodies responsible for the two areas will not help to solve that problem.
As for mandatory awards, the Government are wasting their money if they do not accept the submissions of those in another place. Courses were established to meet the training needs of the profession. Sufficient places were created to meet the need to get over a fairly long period, a fully trained profession. The places were set up on that basis, and resources were allocated on that basis.
For several years local authorities paid for sufficient people to fill almost all of those courses. As a result of the cuts in local government expenditure, the number of people sent has fallen in recent years. It is stupid for the Government to establish a number of places and then not pay the grants for sufficient people to attend. It is important that that provision should stay in the legislation and not be taken out.
Like my hon. Friend the Member for Wolverhampton, North-East, who is the Chairman of the Select Committee, I appreciate the opportunity to consider the question of child care. We are halfway through a report that will be the subject of many recommendations which could be incorporated in the Bill. I hope that we can put forward either interim proposals or an interim report to improve child care practices.
I welcome the registration of homes for the elderly. I accept the argument of Age Concern that this ought to be carried out on a national basis. Someone who has been turned down or criticised by one local authority must not be allowed to move to another area and set up another home which the local authority must ensure is brought up to standard. Not only is the question of accommodation for old people important, but there is a great need for better support facilities. Home helps and community support systems have been reduced in many areas.
The Minister is aware that I have been asking a series of questions about the problems of senile dementia, and the problem for the caring relative looking after elderly people with senile dementia. There was a television programme last week on that subject. Mention was made 543 in that programme of the National Council for Carers and their Elderly Relatives. It has received large demands from people for advice on how to go about caring for their elderly relatives and what support and services they can get. As a result of the sudden upsurge of interest, they have financial problems. I am not sure whether a specific approach has been made to the Department of Health and Social Security. I hope that finance can be produced to help that organisation to carry out its extemely worthwhile role.
The Government must put far more resources into child care to prevent children from going into care. There is a danger of spending £100 on a child in a children's home or over £30 for a child to be fostered when we cannot find £10 to give to the natural parent to ensure that he or she can cope with the problem and, consequently, make it unnecessary for the child to go into care. It is important that we put emphasis on prevention.
The Government would be given a salutary lesson if they were defeated tonight. If that happened, they would be told clearly that we want more resources to make a caring society. If the Government manage to secure the Bill's Second Reading, there will be a major task to undertake in Committee to ensure that the Bill is improved. We must seek in Committee to harry the Government into producing far more resources so that some of the Bill's good provisions will work.
§ Mr. Laurie Pavitt (Brent, South)
My hon. Friend the Member for Stockport, North (Mr. Bennett) has a deep understanding of the integral nature of all Health Service workers, without whom our hospitals would be very much worse. Bearing in mind the statement made this afternoon by the Secretary of State for Social Services, my hon. Friend's comments on the tremendous work that is done by laundry hospitals are to be commended. The laundries deal with the consequences of blood, vomit and incontinence. It is imperative that there is impeccable coverage to avoid infection. My hon. Friend cannot be too highly praised for the way in which he showed his awareness of that fact. The House should be aware of it too.
One of the arguments of the Conservative party has been shown throughout the day to be a myth. The background to the Bill seems to lie in the Government's recognition that somehow the management of the Health Service is inadequate, bureaucratic and in need of reform. That has been suggested in nearly every contribution from Conservative Members.
The hon. Member for Hove (Mr. Sainsbury) criticised my hon. Friend the Member for Crewe (Mrs. Dunwoody), who spoke from the Opposition Front Bench, for her comments. He said that because we have an understanding and knowledge of the Health Service we feel that only those in the Health Service are likely to be able to provide good advice when changes are considered. I remind the hon. Gentleman that we speak from bitter experience. I note that he is no longer in his place.
The right hon. Member for Leeds, North-East (Sir K. Joseph), who is now the Secretary of State for Education and Science, spent nearly £250,000 of taxpayers' money to pay an American consultancy firm to explain how we should have business efficiency and managerial changes if we were to achieve greater benefits for the patients and the Health Service generally. That was a disaster. When 544 the hon. Member for Hove tells us once again that we must look to the "experts" from big business to tell as how to run our Health Service, do not wonder that my hon. Friend the Member for Crewe looks slightly askance at such a proposition.
The myth is being perpetuated that the Health Service and its 1 million employees are inefficient. The hon. Member for Canterbury (Mr. Crouch) and I have served on regional health authorities. We know that the myth about inefficiency is as far from the truth as it is possible to get.
My right hon. Friend the Member for Norwich, North (Mr. Ennals) was chided on his contribution to the debate. The Minister for Health said that he had left behind him all the odds and ends that needed to be cleared up and they now appeared in the Bill. My right hon. Friend had to leave behind some odds and ends because the Labour Government, when they assumed office on 1 April 1974, were saddled with a completely changed Health Service structure. Even the Conservative party has had to introduce a mark 2 change.
It is against that background that we must consider the Bill. One of the most important factors to understand is the way in which domiciliary and primary care can be linked to form an integral part of the Health Service. We judge the Minister for Health on not only his words but his actions. We have never been allowed to discuss the Acheson report on primary care and the Government have never given their opinion on the report's recommendations. They have told us again today that they are concerned about primary care, but the proof of the pudding is in the eating. Let them introduce a debate on the Acheson report so that we may test the extent of their concern. We shall be able to gauge their concern when we know whether they will accept or reject the report's excellent recommendations.
The important part of the Bill deals with the expenditure that will be transferred from the National Health Service budget to the social services budget. My hon. Friend the Member for Crewe made the pertinent point that unless there are more resources the Government wll be robbing Peter to pay Paul. Rate support grant, which has affected social services in every hon. Member's constituency, has been cut drastically in the past three years. That cut has affected the very social services that have been helping to keep elderly people out of geriatric wards. The social services cannot be buttressed simply by taking from the NHS budget unless one is prepared to put more money into social services. My hon. Friends have produced statistics that support that point of view.
Moreover, we must consider in Committee the long-term planning of homes and warden assistance and other means of keeping people out of old folks' homes, as the Black report urged. There must be at least a five to 10-year projection of the capital programme. It is not simply a case of the angle at which one examines the resources. We must project for the long term. It is not possible to build houses or anything else in five minutes. That must be clarified.
Many of our hospitals still have the benefit of being surrounded by acres of land. The Government are now selling off that land. Do they intend to sell that land to private firms which will make a profit out of it, or will it be available for joint arrangement between the social services and the health provision? Liaisons and joint 545 committees are always clumsy. There could be a better way of dealing with that problem. I shall deal with that later.
The Minister made great play of the need to harness the maximum involvement of the voluntary sector. Again, the proof of the pudding is in the eating. We were told today that, to enable private companies which are contracting out of the Health Service to make a profit, the Chancellor proposes to exempt them from VAT. As the House knows—I have raised the matter only recently—the Royal National Institute for the Deaf and the Spastics Society provide residential and educational accommodation that runs parallel with that provided by the social services, yet they have no exemption from VAT. Such bodies are not being encouraged to provide that type of supplement to the welfare state.
The hon. Member for Canterbury made one of the best speeches of the debate. He always approaches the subject with experience, understanding and a good deal of common sense. I hope that he will not think it unkind if I say that he has more knowledge of the NHS than any 50 of his colleagues, and I do not exclude the Government Front Bench from that 50. I hope that the Secretary of State will not simply consult his officials, though they do an excellent job of work for him and dig him out of his problems. I hope that he will read his hon. Friend's speech.
The core of the problem with the Bill is the way in which the family practitioner committees are being changed. It has already been said that the service provided by GPs should be and, under this Bill, will be incorporated into forms of arrangements with social services. That was first said by Kenneth Robinson, then the Minister of Health, in 1964. We are still waiting for that to happen. At last, it seems the Bill is reaching that point.
It is forgotten that medicine is a comprehensive provision. To divide general practitioners from hospital doctors and community physicians means putting into watertight compartments people who are dealing with the same patients. If the patient moves, the general practitioner is in an isolated compartment. One Conservative Member asked how general practitioners had managed to retain their independence over so many years, under Governments of both parties. The local medical committee has always been strong enough to have direct access, outside the structure of the Health Service, to the Minister. That is retained in the Bill.
The family practitioner committee needs to be part of the district health authority. It needs to be part of a medical advisory committee that advises hospitals and the housing department of the social services department of the local authority. The general practitioner should find his place there, not out on a limb.
All Governments seem to have little regard for the cinderellas of the Health Service—the professions that are supplementary to medicine. There has been a great increase in the number of senior citizens, and by the end of the decade there will be 1 million people over the age of 80. Why is there no chiropodist on the family practitioner committee? There are dentists, opticians and pharmacists. Feet are as important as the rest of our bodies. Elderly people can be crippled by corns, and as a result they can be housebound. More resources should be spent on that aspect of medicine. Chiropodists should be 546 on family practitioner committees, to ensure that chiropody is not the last in the list to receive capital resources.
I am worried about the way in which the Secretary of State seems to be acquiring power unto himself. Previously, local bodies had a say, but now it is only the Secretary of State who, in his wisdom, will appoint the family practitioner committee. He will be the only person to appoint the Central Council for Education and Training in Social Work. Some months ago I raised an issue that arose in my area, when the Under-Secretary of State wrote to ask about the political affiliations of the Brent borough councillors serving on the local family practitioner committee. In spite of the words of the Minister for Health this afternoon, we are worried that there will be an increasing number of political appointments of people who have no real understanding of the Health Service and who themselves use private medicine and go to Harley Street.
When I was chairman of my party's health group many years ago, we had a Labour Health Minister for the first time for 13 years. I led a deputation to have more members of my party on health committees. Our request was turned down flat. We were told that it would be wrong for a Labour Minister to appoint Labour Members to health committees. I wish that the present Secretary of State were as conscientious as Kenneth Robinson.
§ Mr. William Hamilton (Fife, Central)
It is not unusual that, although this is a United Kingdom Bill, approximately 15 minutes have been allowed for Scottish Members on the Opposition side to take part. There is not a Scottish Member on the Government side, and the Scottish Minister is certainly not going to reply to the debate; he is going to sit while an English Minister replies to a debate which greatly concerns Scotland.
§ Mr. Hamilton
That is 100 per cent. more than the Social Democratic party that the hon. Gentleman represents.
The Minister expressed surprise that we were opposing the Bill. The reasons for our opposition are simple. Some of the provisions are bad to the point of being indefensible. The Bill has been oversold and the benefits that the Government claim will derive from it will not accrue. They can express the finest sentiments they like; but, if there is no cash to back them up, they cannot deliver the goods. That is the basis of the protest that we have had from Scottish authorities.
Nowhere does the Bill specify the type of case or service for which payment can be made. Both long-term and short-term cases, in-patients and those receiving domiciliary care, can be involved. In other words, the Bill will allow a health authority to contract out of providing a service for people in need of care if it feels that such a service can be provided by a local authority department or a voluntary body, however hard pressed that authority or body may be.
The Bill does not therefore have as its primary aim the removal of patients from hospital, but opens the way for the increased provision of services currently provided by the National Health Service by non-National Health Service and non-statutory bodies—an expansion of the caring role about which the Prime Minister and Members of her Government always talk.
547 We should not deride the activities of the voluntary organisations. However, we look with the greatest suspicion at the declared policy of the Government to resort increasingly to the begging bowl rather than to the taxpayer or to rely on a flag day rather than to regard this as a national responsibility.
It is regrettable that this is a United Kingdom Bill, because the difficulties for Scottish Members are not unknown to the Minister, and he will face the same problems. The only separate Scottish legislation that we have to come now is the Mental Health (Amendment) (Scotland) Bill [Lords]. I want to be on that Committee. I would also like to be on this one. This is the difficulty of mixing Scotland with England in these measures. We have our own legal system, our own education system and our own separate Health Service. There are no family practitioner committees in Scotland. Yet the mugs—I had better rephrase that—the Scottish Members who will be dragooned on to this Committee will have to sit idle while the English and Welsh Members drone on about England and Wales. We shall have to sit mute until we come to clause 2—and then we shall go to town. Scottish Members will make hay of it.
The Scottish Council for Single Homeless has written to all Scottish Members on behalf of 10 other organisations—from the Convention of Scottish Local Authorities to Age Concern. It points out, as was pointed out to the Public Accounts Committee earlier in this Session, that the existing support financing scheme in Scotland in 1982–83 had about one fifth of the resources available to England. This could be put another way. For every £1.82 per head in England, the figure was 39p per head in Scotland or, to achieve parity on a per capita basis, the Scottish provision of £2 million in 1982–83 would have to be increased to more than £9.5 million in 1983–84. The letter also points out that, because strict limits are imposed on the proportion of financial assistance that can be given and the duration of such assistance, local authorities are reluctant to participate in schemes knowing, ultimately, that the whole cost will fall on them. If this scheme is to have any success at all, particularly in Scotland, the resources available must be substantially improved.
No one with a spark of humanity will fail to concede the proposition that the more people we can keep out of hospitals or institutions and in the community, the better. That is highly desirable, not necessarily because of expense—it is not necessarily cheaper—but because it is better for everyone concerned. I have watched television programmes on this subject recently. Too often today community care means granny being cared for by an aging daughter or son or whatever.
In Cowdenbeath, a few weeks ago, I met a middle-aged woman—very nearly an old age pensioner herself—who was looking after her 85-year-old mother. She could not get away for a holiday. She asked me to try to get that old lady into hospital for a fortnight, but the hospital could not provide facilities for her. When I visited the house, that lady had to lock her mother away because, I was told, she might be violent to us if she thought that I was there to take her away from her daughter. We have seen such problems many times on television over past weeks.
"Care in the Community" is a meaningless doctrine unless it it backed by resources. It is no use the Government saying that the Opposition wish only to hurl money at problems. The Government hurled money at the police and at the Falkland Islands. They are spending £2 548 million a head for a population smaller than that of a small village in my constituency, but they cannot afford the money to look after the old, the maimed, the crippled and the mentally handicapped. That is an outrage.
The Government are guilty of a gross dereliction of duty in the way they allocate resources. That is why we are deeply suspicious of the Government's aims in the Bill. It is tantamount to putting a dummy steak in a Dutcher's shop.
§ Mr. Hugh D. Brown (Glasgow, Provan)
I shall not try to compete with my hon. Friend the Member for Fife, Central (Mr. Hamilton), but I shall supplement one or two of his comments.
I apologise for having been absent for a fair amount of the proceedings, but other meetings take place in this building on a Thursday evening, as everyone knows, and I happened to be involved elsewhere. Nevertheless, I am genuinely delighted to be able to criticise the Scottish Office Minister in his presence rather than do so in his absence. He will have discovered by now that the worst thing of all about being a Minister in the Scottish Office is to have to deal with a piece of legislation which is really only an insert into an English and Welsh Bill. The Minister has my sympathy, because I do not know how he will deal with the Mental Health (Amendment) Bill and presumably cover this Bill as well.
I wish to raise one or two Scottish points and one point on the adjudication procedure. On a day when The Guardian has leaked the document about the family, 'NF" is quoted as saying:Give more emphasis and encouragement to community-based services like day or short-term care.Lest the Minister does not know, "NF' is the Secretary of State for Social Services.
It would be remiss of me not to support my hon. Friend the Member for Fife, Central on the Scottish aspect. No doubt we will not get a reply this evening. Presumably that will be done in Committee or on Report. It would be better if the matter could be cleared up when the hon. Member for Argyll (Mr. MacKay) meets the Convention of Scottish Local Authorities next week. What is the difference between the proposals for England and Wales and those for Scotland? Is it right that the contribution by health boards will be allowed to last for only five years in Scotland, against 10 years or longer in England? Whatever thoughts the hon. Member for Argyll has, he is a political animal, and he will appreciate that that should be cleared up as soon as possible.
I had the misfortune to watch the hon. Gentleman on television on Sunday. I hope that I am not being too patronising when I say that he must do better and genuinely consider the problem rather than attempt to score political points. Local government is not popular anywhere, and certainly not in Scotland. It does not matter whether authorities are Labour-controlled or Conservative-controlled. Unfortunately, like the trade unions, they are not popular.
The hon. Gentleman must act like a Minister. He should ask himself why local authorities are not taking more advantage of the resources that are available to get people out of hospital. When he meets COSLA next week, he should remember that in Scotland circumstances are not as favourable to local authorities as they are in England. He had better think about his future, because "NF" has 549 committed him to this. He must realise that there is a problem. He will find that there is good will all round even though there is almost a state of confrontation between local authorities and the Government in Scotland for other reasons. If he could extricate the problem and have it discussed rationally, there would be some response.
It is appalling that in Scotland there are in hospitals 2,000 people who could be living in the community. No doubt the hon. Gentleman and I agree that some people will never come out of hospital, so this is not an issue on party lines.
I do not understand the additional powers being given in schedule 6 to the Secretary of State for Scotland in regard to the disposal of land. I know that the Government want to flog off everything these days, but I am not aware that health boards have any difficulty in selling surplus land. This may be a parochial point, but it was done in the case of Robroyston hospital. I do not know why new powers are necessary. Perhaps the hon. Gentleman will comment on that.
In regard to the appeals procedure and the proposed merger, the press notice issued by the Department says:This is strengthening the quality and independence of the social security appeal arrangements".If the quality needs to be strengthened, that must mean that there is something wrong with the existing set-up. I do not think that has been proved. As an ex-civil servant, I can see the tidy Civil Service mind at work. Because there is new social security legislation, civil servants think that the three categories of adjudication officer should be given the same title, although they will not be doing the same job. I listened to the Minister, but I did not hear why there is a need to change the procedure.
What anxieties and worries do the Government have that makes them think we need to strengthen the quality and independence of the social security appeal procedure. I am not against change. I do not think that lawyers are God's gift to common sense, which is sometimes more important than an understanding of the law. If there were a proper injection of laymen, trade union representatives and people from the community, I should not quarrel too much with the proposed procedure. In Committee the Government will need to make a case for the change, because there is much concern over this issue especially among the TUC and the trade unions, which have played a part in making the machinery as successful as it has been.
I do not expect the Under-Secretary of State for Scotland to reply to any of my comments other than my point about adjudication. I do not know whether the Minister will be in Committee. The Scottish Office is not only not good, but there are not enough Ministers around. I should not say that when I have been trying to appeal to the Minister's better nature, but I do not know whether there will be a Scottish Office Minister in Committee. I hope that the Whips will ignore the fact that I have made a contribution to the debate, because I do not want to be on the Committee. I urge the Minister to take on board the Scottish content of the Bill and deal with it generously and, I hope, sympathetically when he meets COSLA next week.
§ 9.1 pm
§ Mr. Brynmor John (Pontypridd)
For one thing only do I envy the Conservative party—its ability to have 550 amnesia. The moment Conservative Members become the Government all is responsibility and propriety and they expect other parties to match their image of themselves. However, once they become the Opposition, they become totally irresponsible, doing whatever they like and whatever they can, but they rarely remember that afterwards.
I am sorry that the hon. Member for Hove (Mr. Sainsbury) is absent. No doubt he is an heir to the amnesia that afflicts the Conservative party, and he has forgotten to return. He talked about there being factious opposition. I shall justify our division of the House. Any party that perpetrated a filibuster such as the one that took place on the Race Relations Act 1976 for the whole of a Thursday night to lunchtime on a Friday in the most disgraceful fashion had better not lecture anyone about factious opposition.
Part of Eli Jenkins' prayer about the residents in Milk Wood applies to the Bill:We are not wholly bad or good".However, there are sufficient bad points about the Bill to justify a vote, and, as my right hon. Friend the Member for Norwich, North (Mr. Ennals) said, some things are excluded from it, such as generic substitution. Therefore, a vote against the Bill, which is a ragbag with no central theme, is justified.
A vote is even more justified when, as several of my hon. Friends said, the Bill is measured against the present need and the climate surrounding the Health Service and the welfare state. The Government will regret that The Guardian got hold of the confidential Cabinet documents. Like many other hon. Members, we are not interested so much in debating the minutiae of the Bill when there is a threat to the Health Service and the welfare state of such magnitude, as was stated in that newspaper. The documents' existence was not denied by the Prime Minister at Question Time. They threaten us with a social engineering that is chilling and promise us the transfer of whole sections of the population to either private provision or private charity.
Those of us close enough to the 1930s to remember the degradation and destitution which such a philosophy spawned in Britain know what this means only too well. If the document is right about the Government's intentions for the NHS, that is what we ought to be debating, not a miscellaneous provisions Bill. Therefore, as we demanded at business questions this afternoon, the Government should put before us the Tory vision of the family as contained within that document so that it can be debated in full and so that we can have their intentions out in the open. What we are debating tonight may be bad, but we fear that there is much worse to come and only an early debate in Government time will satisfy the country on that matter.
The Minister for Health, who kindly said that he would not be here for the start of my speech, mentioned voluntary provision, and that was taken up by many Conservative Members. I now know the town of Lincoln very much better since the speech of the hon. Member for Lincoln (Mr. Carlisle) than I did at the beginning because he went round Lincoln voluntary institution by voluntary institution. However, we need no lectures about voluntary agencies and a proper regard for them. The Prime Minister is fond of telling us about the Victorian virtues. Let me tell the Minister about the Victorian virtues as they 551 affected the Labour movement. The Labour party built its own education and hospital institutions so we shall not take lecturing about the need for voluntary institutions.
We believe that voluntary provision has a supportive role to play in the NHS. It certainly cannot be a substitute for state provision, but it can be a valuable adjunct and most of us have played a part in such hospital services as members of the leagues of friends of hospitals and by other means of voluntary participation in Britain's health care. However, I did not hear a word of tribute from any Conservative Members for the people working within the NHS. They are the people who are low paid and who work with much dedication and a great deal of personal inconvenience, as my hon. Friends the Members for Stockport, North (Mr. Bennett) and Wolverhampton, North-East (Mrs. Short) pointed out. We are complaining not about the mention of the voluntary sector but that 20,000 places can command the total absorption of Conservative Members with the honourable exception of the hon. Member for Canterbury (Mr. Crouch), with no recognition of the hard and devoted work of NHS workers. That should be remedied if the Conservative party is to retain our sympathy.
There are three main points on health matters which are unresolved and unsatisfactory and which deserve division. The first concerns the family practitioner committee. The Minister said that it was purely administrative but then let the cat out of the bag by saying that there were two reasons why they wanted that—first, cash limits and, secondly, direct accountability to the Government.
An industry which has recently been made more independent is the water industry which was reorganised for the second time in my experience as a Member of Parliament in order to have less public representation on it and it was to be independent. In the recent dispute we have all seen just how independent a cash-limited, Government-appointed body can be when the crush is on. That gives us no pleasure at all.
The hon. Member for Canterbury was quite right to say that to take the family practitioner committee away from the integration of the three arms of the NHS is both out of step and out of time. It is necessary to promote the integration and to get people working as closely together as possible. If I understand the position correctly, I believe that in Scotland the FPCs are part of the DHAs. It can be done there and I believe that that is the way we should go rather than making them allegedly independent.
It is more ironic than that. I said that it was the second reorganisation of the water industry, because in a paroxysm of guilt the Government have to get rid of everything that the Heath Government did. The right hon. Member for Sidcup (Mr. Heath) is being written out of history quicker and more assiduously than Joseph Stalin is being written out of Russian history. The hon. Member for Canterbury and I were on the Committee in 1973 which dealt with the reorganisation of the National Health Service, and the Government's proposal to change the status of the family practitioner committee is undoing the work that the Government did then. The then Secretary of State for Social Services is now the Secretary of State for Education and Science. He apparently is more adaptable than some of the forms of government that he then introduced.
We oppose the Bill because we believe that there is a need to integrate, and we believe that the Government's proposals make that integration more difficult.
552 My second point is on community care and joint finance. In a legal aphorism, it is suggested that, like the Ritz hotel, justice is open to all. There is no point in having a notional development of a theory without the money to back it up. Community care is a great concept which is being backed by a minuscule amount of money. That is why we oppose it.
Thirdly, we oppose charging as provided for in part VII. The House of Lords passed an amendment enabling a local authority to charge what it believed to be reasonable and deleted the phrase about having regard to the person's means. The Minister seemed genuinely puzzled by the amendment. I hope that he will give us an undertaking that the Government propose to restore it in Committee, otherwise the point made by right hon. Friend the Member for Norwich, North that local authority services are being charged to people whose only income is supplementary benefit will be a reproach to us. Lord Trefgarne made sympathetic noises about the removal of that category of people from charges. He said that discussions were going on with local authorities to agree a formula to overcome it. Will the Minister tell us what progress has been made?
I wish to deal mainly with the part of the Bill relating to social security adjudication. My hon. Friend the Member for Birkenhead (Mr. Field) said that the tribunals are the courts of the welfare state and that therefore we should not underestimate the number of people who are involved. While in Opposition, some members of the Government tended to create the impression that those who received social security benefits were oddballs and exceptions in society, whereas we all know that social security payments are received regularly by roughly half our people. Therefore, that which affects social security affects at least half the people in our society, and any change in adjudication will be vastly significant.
My hon. Friends the Members for Birkenhead and for Stockport, North were worried about the quality of service, but I shall return to the later.
Another great worry is how and by whom the appellant is to be represented. In a system that is increasingly becoming precedent-bound by cases and commissioner decisions, the appellant who appears in person is often totally bewildered and at a disadvantage. If the Government were sincere in saying that the world had moved on and that what started as an informal system could no longer be informal, they would extend legal aid to the tribunals so that appellants were properly represented or they would fund the voluntary bodies so that they could provide representation.
Several hon. Members have mentioned the membership of the tribunals. At present tribunals include, as of right, people who have experienced working conditions and social and financial backgrounds similar to those of claimants. It is vital to have them on tribunals, and it is even more important that they should be independently nominated. At the Home Office we had a list of the great and the good at national level. I suppose that at local level it would be a list of the mediocre and the moderate. However, they would be appointed by the Secretary of State. His ability to sift through the nominees and to choose those who would represent his wishes is a disabling provision because he may not choose those who would best represent the claimant.
There should be independent nominations by trade unions and trades councils and there should be—the Bill 553 does not contain this and it has been insufficiently noted—an obligation on the Secretary of State to accept those nominations. The phrase in the Bill has been changed toBefore appointing members to a panel, the Secretary of State may take into consideration".However, he may not take those members into consideration. They should be appointed as of right and they should have a guaranteed place.
Some hon. Members talked about the chairmen of tribunals. One's view depends upon whether one likes lawyers. I declare an interest as a lawyer and, on the whole, I like myself. However, there is a serious question about whether the present mixture of lay and legal chairmen is correct. The Bell report recommended the appointment of legal chairmen. One reason for that is that we must accept the fact that many decisions of the supplementary benefit appeal tribunals are being overturned on appeal, which must be a reflection of the quality of the tribunals. However, that does not mean that being a lawyer is the sole qualification for being a tribunal member.
Even if we accept that a legally qualified chairman will be the norm, the chief adjudication officer should have power to recommend to the Secretary of State that if a chairman is doing a good job, but he has no legal qualifications, he should be allowed not only to serve out his present term but should be reappointed. We should not sacrifice good lay chairmen because they lack legal qualifications, any more than we should sacrifice good magistrates' clerks who are not legally qualified just because the norm is to have legal qualifications.
There are a number of points about the ostensible reason for the amalgamation—efficiency. As my hon. Friends the Members for Birkenhead and Stockport, North said, it is no good ensuring that the quality of the decision is improved without certain other things. The first is the speed in the hearing of the appeal. I understand that in London appeals are three months in arrears. When people are living on small sums of money, that is a denial of justice, not in any decision that is taken but in the time that they have to wait for the appeal to be heard. I hoped that one of the reasons for the amalgamation would be the speeding up of the procedure. However, that depends upon the number of tribunals that are set up to replace the present separate tribunals, and the frequency with which they sit. Before we can form a judgment, we must have some more information about what the Government propose.
The distinction between the supplementary benefit tribunals and the national insurance appeal tribunals is being abolished. That will not be satisfactory if, within the offices concerned, there continues to be a distinction between the supplementary benefit and national insurance parts of the office so that when there is a supplementary benefit appeal a supplementary benefit officer is sent to represent the DHSS, and when there is a national insurance appeal a national insurance man is sent. There will be a proper saving and mixing of the two only when, at local office level, we have the mixing of the staff. Is that mixing proposed, or is the only unity to be at an appeal level?
We are placing upon the members of the new tribunals, whoever they may be, one of the most onerous jobs of any member of any tribunal, because to prepare themselves for 554 appeals of this kind they will not only have to master the two yellow books for supplementary benefit but there will be no fewer than four brown books for the national insurance law and regulations and cases. This is a tremendous job. Therefore, we must do several things. We have to present the members with adequate material, and there is much evidence that not all the tribunal members are getting their material or the supplements to the books on time. Have some of these books been published? We had a debate about this a year ago, but the matter appears to be in limbo, and I should welcome some information about the availability of the up-to-date books and their price. That also affects the ability of voluntary organisations to represent appellants.
We need to set up for all members of the tribunal, both those who are reappointed and those who are appointed for the first time, a proper system of training. The Government have not been living up to that condition. Not only do the members have to be trained, but refresher courses should be undertaken from time to time because of the array of the commissioners' decisions and the hair-splitting that is implicit in some of those decisions, which is truly bewildering. If we expect the members of the tribunal to do justice on our behalf, we have to train them properly.
My hon. Friend the Member for Birkenhead spoke about the independence of tribunals indirectly when he asked whether it would be ideal for us to have a legally qualified clerk rather than a legally qualified chairman. In my experience, the existence of a legal clerk does not remove the necessity for a legally qualified chairman, as the stipendiary magistrates system proves. However, there is an important point here that deserves an answer.
At the moment, the staffing of the tribunals is done by people seconded from the DHSS for a certain time to fulfil their role as clerks to the tribunal before returning to the system. As my hon. Friend has said, it is inhibiting for a clerk employed by the DHSS to be expected to be firm and tough with members of his own Department when he knows that he will have to work with them again and that his own promotion chances rest upon that.
If the Government feel that the time has come to set up this system, to be consistent they must also provide the appeals system with its own machinery and servicing and its own career structure. The chairman or the chief adjudication officer should be responsible for recruiting and employing people who must be seen to be independent of the Department on the advice of which the tribunal may be expected to act impartially.
I shall now deal with what is not in the Bill. The Government take great pride in setting up this huge new appeal system that they believe will be so much better than the previous system. That being so, what is the position with regard to appeals about housing benefits? At the moment, the arrangements are truly pitiful. The person denied housing benefit has the right to appeal to a committee of the same council that denied him the benefit. Indeed, the same members of the committee who made that decision often deal with the appeal. That does not even appear to be justice, and as time goes on it will increasingly be regarded as both ramshackle and unfair. I know that the Minister regards the housing benefit scheme almost as he would a gifted child of his own. He has a certain paternal interest in it and takes umbrage when none 555 should exist. Nevertheless, unless he deals with the appeals structure his brainchild will suffer grievous mental damage before very long.
My hon. Friend the Member for Ormskirk (Mr. Kilroy-Silk) asked about children in care and the attitudes of some local authorities towards the natural parents. Although the care procedure is intended not to be adversarial, the local authority often develops thoroughly hostile reactions towards the natural parents, from whom it has taken the children because it regards the parents as unfit to care for them, to such an extent that the authority is extremely reluctant to grant any access for the parents to see the children. The authority may also refuse to give any information about fostering, how and by whom, with the result that great friction is engendered between the foster parents and the natural parents. That is neither inevitable nor desirable. First, and most important, it scars the child who must be aware of the tension and friction caused by such quarrels. Secondly, it scars the natural parents. We must avoid dealing with them in a draconian way. They may well be parenting other children, so one hopes that their attitude towards children will improve rather than deteriorate as a result of that experience.
The Government must take a far broader and deeper view of the subject of children in care and give wider representation to the parties at the care proceedings than they are at present prepared to do. Too often the local authority gains custody almost on the nod, certainly without adequate representation for all parties. That is not the best way to deal with the matter.
To sum up, the Bill is the repository of some matters that we do not consider objectionable. It is the repository of some things that we believe can be improved greatly in Committee. It is the repository of some things that we find objectionable in principle. However, our chief criticism is that it does not match up to the scale of need within the welfare state. It does nothing to answer the real anxiety felt by millions of people about the intentions of the Government towards the welfare state. We fear that another Conservative Government, if that misfortune was ever to happen, would mean the destruction of the welfare state. It is because the Bill does nothing to deal with the central questions that beset us that we intend to divide the House.
§ The Under-Secretary of State for Health and Social Security (Mr. Tony Newton)
I had expected to be able to start my remarks by referring to something that I might have described as a general but grudging welcome for the Bill or at least most parts of it. I still find that that, in effect, has been the tone of most of the speeches, yet they have somehow been put together in an extraordinary edifice which now persuades the Opposition apparently to vote against the Bill although they approve of almost every part of it. [Interruption.] I accept the qualification of the hon. Member for Newcastle upon Tyne, East (Mr. Thomas), representing the SDP, that only one part of the Opposition will vote against the Bill.
So far as I can judge from the many interesting points that have been made in the debate, the only part of the Bill to which Opposition Members strenuously object, and which they feel has virtually no merit, is that dealing with the status of family practitioner committees, about which I hope to say a few words. In effect, the intention of the Labour Opposition to vote against the Bill rests entirely on 556 issues that are extraneous to the Bill. I understand the reasons. I do not particularly resent or object to such an attitude. It should, however, be put firmly on record that this is not a Bill that either does, or could, deal with the bringing of large additional resources to health and social services.
The Bill is concerned with the machinery by which resources are applied within the health and social services and the social security adjudication system. It improves the efficiency of our use of the resources that we possess. It would be possible for me to make a speech, and, indeed, I intend to make some remarks, on the issue of providing resources. It should, however, be clearly on the record that that is not the fundamental purpose of the Bill. To vote against a Bill that contains, as most hon. Members will accept, many good and useful provisions solely on the ground that if this were a debate about public expenditure there would be a vote against the Government has a slightly strange air about it.
Given that a good deal has been said about money, I might perhaps be allowed to say a little. No one listening to the remarks from the Opposition Benches would dream that those remarks were directed at a Government under whom spending on the National Health Service had risen significantly in real terms and under whom spending on the personal social services had risen significantly in real terms by nine per cent. between 1978–79 and 1982–83. The indicative figures for local authority expenditure this year show that the Government have placed no less than a quarter of the increase in personal social services, when social services represent only 10 per cent. of local authority expenditure, which is a clear lead. The plans for the next three years continue to give local authority social services a two per cent. lead in these terms over the indicative figures for other parts of local authority spending.
§ Mr. Ennals
Surely the hon. Gentleman should be extremely angry with those local authorities which have been spending above their limit on social services. The fact that they have done so has been in spite of pressure from the Government to reduce their expenditure. It is those local authorities which care that have done so, and as a consequence they have been penalised.
§ Mr. Newton
I see no reason why I should be angry with local authorities which have to a significant extent done what the Government have urged, which is to concentrate the resources available to them on priority areas, including substantial parts of the social services. My right hon. and hon. Friends have consistently hoped that local authorities would look at the pattern of their expenditure with a view to concentrating on priorities, and have stated what some of those priorities should be.
I say for myself and for my right hon. and hon. Friends that I am glad that local authorities have recognised the importance of social services in planning their budgets over the past few years. I hope that they will continue to recognise the importance of social services in the next few years. It is clear that the decisions which many hon. Members on both sides of the House wish to see made to achieve the objectives which we hold in common are decisions which depend on what happens in local authorities and cannot be dictated in every respect by the Government.
We cannot expect to run the personal and social services from Alexander Fleming House. Guidance and 557 exhortations can be issued and authorities can be congratulated rather than condemned when they respond to the Government's hopes for the priorities that they will place on social services expenditure and on expenditure for those with special needs.
My final point about money ties in with points that have been made by various Members, including the hon. Member for Ormskirk (Mr. Kilroy-Silk), who told me that he would not be present for the winding-up speches. One would not have recognised from what was said tonight that in the past few months the Government had announced a series of significant initiatives to deal with many of the problems of current concern. There have been initiatives on drug abuse, on additional help for the under-fives and not least on the problem of the one-parent family, about which the hon. Lady waxed so eloquent.
The Government have announced new initiatives on the improvement of services for the elderly and the severely mentally infirm. This issue was touched on by a number of hon. Gentlemen, not least the hon. Member for Stockport, North (Mr. Bennett), who has also apologised to me for not being present now, and who is concerned about the problem of senile dementia.
Within the last two or three weeks there has been a sizeable initiative on intermediate treatment, designed, as I said when intervening in the speech of the hon. Member for Ormskirk, to earmark funds for the development of the important technique of treating and helping young offenders in the community.
Nor would one have recognised from what has been said—in fact it was ignored by several hon. Members—that the Government have been increasing the funds going into joint finance. The Government have recently announced an additional £6 million for the forthcoming year in connection with the attempt to move further forward on the policy of care in the community, which is supported and encouraged from both sides of the House.
§ Mrs. Dunwoody
Does the Minister accept that if direct finance to local authorities is cut back there is no point in giving a small amount more for joint financing? That point has been made time and time again.
§ Mr. Newton
I do not accept that. The joint finance programmes that have developed within the past few years have grown and developed significantly. The Government have given a sizeable boost to the development of community services of the kind needed for developing these initiatives.
I do not think the hon. Member for Crewe has fully recognised some of the ingredients of the new proposals which the Government are bringing forward on care in the community. The £6 million of additional money is not designed just to help local authorities cover that period when resources are being released from the Health Service towards care in the community. Health authorities will be given power outside the joint finance arrangements to transfer sums of money to those patients who are leaving long-stay hospitals for community alternatives.
I do not claim, and nor do my right hon. and hon. Friends, that the Bill goes as far as we would like. It would be absurd to make that claim. However, it is equally absurd for the hon. Member for Crewe (Mrs. Dunwoody) and her hon. Friends to pretend that it is not a useful and 558 welcome development that will help to bring about the progress that we all wish to see. The Opposition do themselves no service, nor the House or those whose interests they seek to speak for, by minimising what is being achieved and planned.
The hon. Member for Fife, Central (Mr. Hamilton) talked about joint finance in Scotland. In this respect I adopt the comments of the hon. Member for Glasgow, Provan, (Mr. Brown) about the meeting that my hon. Friend the Under-Secretary of State for Scotland will have next week with the representatives of the Convention of Scottish Local Authorities to discuss joint financing. The problems which the hon. Members for Fife, Central and for Provan raised will be discussed at that meeting.
§ Mr. Hugh D. Brown
It is kind of the Minister to refer to the Scottish context, because I am sure that he knows nothing about it. Will he take on board the fact that there are different circumstances in Scotland? I am not suggesting for a moment that he can instruct the hon. Member for Argyll (Mr. MacKay), the Under-Secretary of State for Scotland, but perhaps he will try to understand that Scottish local authorities are anti-Government because the Government are trying even now to place additional burdens on local authorities under the joint financing scheme.
§ Mr. Newton
It is right that my understanding of the Scottish context is limited. The hon. Gentleman is even more right to suggest that as a DHSS Minister in London I am in no position to issue orders to my independent Scottish friends in Edinburgh. No doubt my hon. Friend the Under-Secretary of State for Scotland has heard what has been said and will have marked, learnt and inwardly digested it for his talks next week.
Many hon. Members, especially the hon. Member for Wolverhampton, North-East (Mrs. Short), have observed that the Bill will make a number of changes to children's legislation and provide increased protection for vulnerable groups of children and prevent their unnecessary suffering. The hon. Lady referred to some of them and I am grateful to her for the welcome that she gave to these measures. They may appear to be small, but they may prove to be quite large in protecting a small number of children who are subject to particular risks in the community. The provisions for children and child care may be relatively limited, but it is clear from the discussion that took place in another place, and from what has been said tonight, that there is considerable interest in the possibilities of making the Bill rather larger in its application to child care. Considerable concern has been expressed about a number of matters which at present are not covered by the Bill.
It was clear from the speech of the hon. Member for Ormskirk, from a number of other speeches and from what was said in another place that there is much concern about the exercise by local authorities of parental rights resolutions and the granting or denial of access to parents of children in care. The Government understand the concern that is being expressed. In the past few weeks I have met the local authority associations and the Association of Directors of Social Services for discussions on these matters in the light of some recent cases and against the background of what was said in another place during its discussion of the Bill.
I am pleased to say that, although I cannot make a detailed announcement of the Government's proposals 559 today, considerable agreement between all those interested in these matters is beginning to develop on what needs to be done. I shall say more about that a little later.
Before doing that, I should like to emphasise several general points which echo some of the points made by the hon. Member for Wolverhampton, North-East. She spoke with her experience, which we greatly value, as Chairman of the Social Services Committee, which we also greatly value. That Committee is now studying child care legislation. The Department warmly welcomes that and looks forward to examining the report that will appear in due course.
My first general point is that nobody should allow himself to run away with the idea that passing laws can solve many of the problems. In the end, the solution of most of them depends on good practice among those concerned, especially local authority social workers in social services departments. The hon. Member for Wolverhampton, North-East recognised that we are dealing with legislation that has grown up and the complexity of maintaining a balance between the interests of the child, the interests of the local authority that is asked to act as if it were the parent of that child, the interests of the parents and, in many cases, the interests of foster parents who have been asked by the local authority to help it exercise its parental responsibility. One might also have to consider the interests of adopting parents. It is a difficult balance to be sure of getting right. It is definitely one in which it is proper to proceed with caution when one considers changes in the law. I hope that the House will be careful.
Another general point also relates directly to what the hon. Member for Wolverhampton, North-East said. The Social Services Committee is conducting an inquiry into these matters. Many of the witnesses that have appeared before it have suggested the need for a bigger inquiry. The hon. Member for Ormskirk went so far as to demand a Royal Commission. Whatever form that further inquiry takes, there is a growing suggestion that some people feel that the inquiry should be broader.
We shall want to consider what the Social Services Committee finds as well as what emerges in further debate on the Bill before attempting to decide on many of the points that can and may be advanced, including that of a wider-ranging inquiry. For all those reasons, it is clear that whatever we or Opposition Members try to include in the Bill, we shall not be able to cover all the anxieties and pretend that, by amending the Bill, we can have the last word on the delicate and difficult issue of child care.
Nevertheless, that should not prevent us from being willing to examine the most obvious areas of worry and to make changes where they are clearly needed. I hope that, despite the caution in what I have said so far, the House will agree that we should not be inhibited from making any change because of the work of the Social Services Committee or an inquiry that might take place. Down that path lies more or less permanent inertia. That is not what I or the House would wish.
I shall now comment on the major issues. Parental rights procedures, which have become the subject of much controversy, are intended to protect and to promote the welfare of the children concerned. There is general agreement that some mechanism is needed to transfer parental rights to the local authority when that is seen to be in the child's interests. It has been argued that that step should not be taken without recourse to the courts and that 560 the changes that were proposed in another place would do away with the power of authorities to assume such rights by resolution. It has also been argued that the changes would do away with the right of parents to agree that the local authority should take over their rights and duties. It would not be right to go that far in circumstances in which local authorities are often taking over those rights without any difference of opinion with the parents, and when there is no objection or dispute.
It cannot be right to bring in the courts when everyone is agreed about the right course. Clearly there is concern, but, on the subject of whether the courts should be involved in all cases of parental rights, I say that the main need is for improved practices by local authorities. It is in that direction that we are now moving with the local authority associations—and, I hope, the Association of Directors of Social Services—to produce a code of guidance that will enable arrangements for parental rights resolutions to be made against the background of greater co-operation with and information for parents about their rights and the duties of local authorities.
§ Mr. Newton
I took it that there was fairly general agreement with my remarks that the law could not solve some of the problems. I seek to do no more than to reemphasise that and to say that a code is needed, whatever the law may say on the matter.
There are two other points. The extent to which parents have clear legal rights under the existing law on parental rights resolutions is sometimes underestimated. I shall return to one aspect of that matter. In most cases, the local authority must notify the parents of its intention to take parental rights. At that point, if the parents object to the local authority's intention, the authority can proceed only by taking the matter to court. That is a significant right, given that the parents are entitled to legal aid in those circumstances. It is a significant protection against the abuse of local authority power in the way that has been feared. That is about the right balance, as far as I can judge, in normal cases.
However, there is one point in the existing law that clearly needs to be changed, and that is the aspect that allows parents whose children have been taken voluntarily into care to sign in advance that they will not object to the introduction of a parental rights resolution. That means that they do not then need to be notified of the making of the resolution, and they thus lose their entitlement to the right of appeal that I have just outlined. We have concluded that it is right to table an amendment to the Bill to prevent parents signing away their rights in that way. I felt that some disagreement was developing between the two sides. I am glad that Labour Members, now that they have heard all that I have in mind, at least welcome that as a useful move.
As time is short and I have deliberately attenuated my remarks, I shall summarise what I want to say about child care. We recognise the concern that is felt about the balance between the powers of local authorities and the rights of parents. We are anxious to respond to that 561 concern, so long as we can do so in ways that cannot be seen to weaken the paramount need, which must be the welfare of the child or children in question.
In relation both to parental rights resolutions and to the grant of access to children in care, for whatever reason they may be in care, we feel that there is a need for improved standards of practice. We are therefore working in conjunction with the local authority associations to prepare a code or codes of guidance to cover these matters.
Beyond this we are persuaded that the law should be changed to prevent parents from signing away in advance their right to object to the making of a parental rights resolution and thus their right to have the matter dealt with by a court. We are actively considering whether there is a further change that we can appropriately bring forward to meet the anxiety expressed about the position of parents who are refused access to their children in care.
In the few moments left to me, I want to mention residential care homes and the inspection procedures which have been the subject of some comment during the debate. I emphasise that the frequency of inspection set out in the Bill is the minimum. There is nothing to prevent local authorities from inspecting homes more frequently if they wish to do so, and there is certainly nothing to stop the spot checks and the visits without notice, which some hon. Members have mentioned.
It is at present difficult to see how statutory backing for a code of standards could sensibly be applied to such a varied range of accommodation and the needs of such widely different client groups as are currently in these homes. We feel that at the moment the right approach is the voluntary code which we are hoping to construct with the aid of the Centre for Policy on Ageing and which we hope will be produced later this year.
Let me deal quickly with the Central Council for Education and Training in Social Work and the mandatory grants on which hon. Members have touched on a number of occasions and at some length. I cannot, as my hon. and learned Friend indicated in his opening speech, say what our intentions are with regard to the amendment introduced by Lady Faithfull and passed in another place.
§ Mr. Newton
The right hon. Gentleman thinks that I ought to be able to say. I had it in mind to listen to the views of the House of Commons on Second Reading before coming to a decision.
§ Mr. Newton
I have been urged all evening to listen to the House. Now I am told that we should have made up our minds in advance.
§ Mr. Newton
I do not think I am out of step with the rest of the Government. This is a listening Government—[Interruption.]—who are ceaselessly prepared to hear and consider the advice of the House.
It seems to me far from clear that the proposal that has been inserted in the form of an amendment to the Bill in another place will actually achieve the objectives that it 562 and its authors have in mind. The pattern of qualification in social work demonstrates that a very large number—indeed, the majority—of social workers have the sort of training that has been discussed today. The biggest need, as far as I can judge, is to improve the training of the people working in residential care homes and the like. It is not the case that the extension of mandatory awards in the form presently contained in the Bill would necessarily be the best way of devoting additional resources to the main needs for increased training in social work. I put that before hon. Members as one of my own reservations against the background of what has been said tonight in considering the appropriate policy for us to follow.
I hope that Opposition Members will reconsider their decision to vote against what is a modest but useful Bill to improve social work provision.
§ Question put, That the Bill be now read a Second time:—
§ The House divided: Ayes 105, Noes 43.563
|Division No. 71]||[10 pm|
|Alexander, Richard||McCrindle, Robert|
|Alison, Rt Hon Michael||MacGregor, John|
|Alton, David||Major, John|
|Aspinwall, Jack||Marlow, Antony|
|Banks, Robert||Mather, Carol|
|Beith, A. J.||Maude, Rt Hon Sir Angus|
|Bendall, Vivian||Mellor, David|
|Bennett, Sir Frederic (T'bay)||Meyer, Sir Anthony|
|Benyon, W. (Buckingham)||Miller, Hal (B'grove)|
|Berry, Hon Anthony||Mills, Iain (Meriden)|
|Biggs-Davison, Sir John||Moate, Roger|
|Blackburn, John||Murphy, Christopher|
|Body, Richard||Myles, David|
|Boscawen, Hon Robert||Nelson, Anthony|
|Braine, Sir Bernard||Neubert, Michael|
|Bright, Graham||Newton, Tony|
|Brinton, Tim||Normanton, Tom|
|Brooke, Hon Peter||Osborn, John|
|Bruce-Gardyne, John||Page, John (Harrow, West)|
|Carlisle, John (Luton West)||Page, Richard (SW Herts)|
|Carlisle, Kenneth (Lincoln)||Penhaligon, David|
|Carlisle, Rt Hon M. (R'c'n)||Prentice, Rt Hon Reg|
|Clarke, Kenneth (Rushcliffe)||Proctor, K. Harvey|
|Cope, John||Renton, Tim|
|Crouch, David||Rhys Williams, Sir Brandon|
|Dorrell, Stephen||Roberts, Wyn (Conway)|
|Dunn, Robert (Dartford)||Ross, Stephen (Isle of Wight)|
|Dykes, Hugh||Rossi, Hugh|
|Emery, Sir Peter||Rumbold, Mrs A. C. R.|
|Faith, Mrs Sheila||Sainsbury, Hon Timothy|
|Fenner, Mrs Peggy||Sandelson, Neville|
|Fletcher-Cooke, Sir Charles||Shepherd, Colin (Hereford)|
|Freud, Clement||Sims, Roger|
|Garel-Jones, Tristan||Smith, Tim (Beaconsfield)|
|Goodhew, Sir Victor||Speller, Tony|
|Goodlad, Alastair||Stanbrook, Ivor|
|Greenway, Harry||Stanley, John|
|Griffiths, Peter (Portsm'th N)||Stradling Thomas, J.|
|Gummer, John Selwyn||Taylor, Teddy (S'end E)|
|Hampson, Dr Keith||Thomas, Mike (Newcastle E)|
|Hawkins, Sir Paul||Thompson, Donald|
|Hawksley, Warren||Thorne, Neil (Ilford South)|
|Heddle, John||Trippier, David|
|Henderson, Barry||Viggers, Peter|
|Hogg, Hon Douglas (Gr'th'm)||Waddington, David|
|Howells, Geraint||Waller, Gary|
|Hunt, David (Wirral)||Warren, Kenneth|
|Jopling, Rt Hon Michael||Watson, John|
|Kershaw, Sir Anthony||Wells, Bowen|
|Lloyd, Peter (Fareham)||Wheeler, John|
|Luce, Richard||Wilkinson, John|
|Lyons, Edward (Bradf'd W)||Winterton, Nicholas|
|Wolfson, Mark||Mr. Archie Hamilton and|
|Mr. Ian Lang.|
|Tellers for the Ayes:|
|Allaun, Frank||John, Brynmor|
|Atkinson, N. (H'gey,)||Lamond, James|
|Bennett, Andrew (St'Kp't N)||Millan, Rt Hon Bruce|
|Booth, Rt Hon Albert||Morton, George|
|Campbell-Savours, Dale||Orme, Rt Hon Stanley|
|Carter-Jones, Lewis||Pavitt, Laurie|
|Cocks, Rt Hon M. (B'stol S)||Powell, Raymond (Ogmore)|
|Cowans, Harry||Prescott, John|
|Cox, T. (W'dsw'th, Toot'g)||Race, Reg|
|Cryer, Bob||Robinson, G. (Coventry NW)|
|Cunliffe, Lawrence||Short, Mrs Renée|
|Dalyell, Tarn||Skinner, Dennis|
|Davis, Terry (B'ham, Stechf'd)||Spearing, Nigel|
|Deakins, Eric||Tinn, James|
|Dixon, Donald||Wainwright, E. (Dearne V)|
|Dormand, Jack||Walker, Rt Hon H. (D'caster)|
|Dunwoody, Hon Mrs G.||Welsh, Michael|
|Ennals, Rt Hon David||Williams, Rt Hon A. (S'sea W)|
|Foster, Derek||Woodall, Alec|
|Hamilton, W. W. (C'tral Fife)|
|Harrison, Rt Hon Walter||Tellers for the Noes:|
|Hattersley, Rt Hon Roy||Dr. Edmund Marshall and|
|Homewood, William||Mr. Allen McKay.|
|Janner, Hon Greville|
§ Question accordingly agreed to.
§ Bill read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Committal of Bills).